MSE:
- Behaviour: The patient appeared restless and frequently shifted in their seat during the session. They also interrupted the psychologist multiple times.
- Mood: The patient reported feeling frustrated and overwhelmed. The psychologist observed signs of irritability.
- Thoughts: The patient's thoughts were coherent and oriented to time and place.
- Cognition: No concerns reported or observed.
Observations:
- The patient frequently tapped their foot and seemed distracted by noises outside the room.
Reason for assessment:
- The patient was referred for an ADHD assessment due to ongoing difficulties with attention and impulsivity impacting their academic performance.
Background:
- Family members: Lives with both parents and a younger sibling.
- Family history: The patient's father has a history of ADHD.
- School and Year level: Attends Greenfield High School, currently in Year 9.
- Pregnancy and Birth History: No significant concerns reported.
- Childhood History: Experienced frequent ear infections as a child.
A) Inattention
1) Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities
- The patient often makes careless mistakes in math assignments.
2) Often has difficulty sustaining attention in tasks or play activities
- The patient struggles to maintain focus during class lectures.
3) Often does not seem to listen when spoken to directly
- The patient frequently needs instructions repeated.
4) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
- The patient often leaves homework incomplete.
5) Often has difficulty organizing tasks and activities
- The patient struggles with organizing their school backpack.
6) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
- The patient avoids reading assignments.
7) Often loses things necessary for tasks or activities
- The patient frequently misplaces school supplies.
8) Is often easily distracted by extraneous stimuli
- The patient is easily distracted by classroom noises.
9) Is often forgetful in daily activities
- The patient often forgets to bring necessary materials to class.
B) Hyperactivity and Impulsivity
1) Often fidgets with or taps hands or feet or squirms in seat
- The patient frequently taps their foot during class.
2) Often leaves seat in situations when remaining seated is expected
- The patient often gets up during class without permission.
3) Often runs about or climbs in situations where it is inappropriate
- Not observed.
4) Often unable to play or engage in leisure activities quietly
- The patient is loud during group activities.
5) Is often “on the go,” acting as if “driven by a motor”
- The patient is described as always being on the move by teachers.
6) Often talks excessively
- The patient talks excessively during class.
7) Often blurts out an answer before a question has been completed
- The patient frequently interrupts the teacher with answers.
8) Often has difficulty waiting his or her turn
- The patient struggles to wait their turn in games.
9) Often interrupts or intrudes on others
- The patient often interrupts peers during conversations.
Symptoms interfere with or reduce the quality of:
- Social Functioning: The patient has difficulty maintaining friendships due to impulsive behavior.
- Academic Functioning: The patient's grades are affected by inattention and incomplete assignments.
- Occupational Functioning: Not applicable.
- Home Functioning: The patient often argues with family members due to impulsivity.
(If described behaviours or examples fit into multiple criteria, only include in the most relevant/salient criteria. Do not list the same example in multiple places. Provide direct quotes where salient information is provided.)
MSE:
- Behaviour: [describe behaviours observed in the session] (describe all relevant observations made about the patient's behaviour during the session)
- Mood: [describe mood of client] (include patient self-reports if available and therapist's observations)
- Thoughts: [describe thought content. Describe whether thought seems coherent, oriented to time and place] (only include descriptions that are observed or reported)
- Cognition: [describe any concerns noted or state "no concerns reported or observed"] (note any cognitive concerns or strengths observed during the session)
Observations:
- [describe any other relevant observations] (include only if relevant observations are noted)
Reason for assessment:
- [describe the reported reason for referral. Any relevant thoughts or notes] (summarize the client's reason for attending the session or referral information)
Background:
- Family members: [describe family members and family structure] (include relevant information about immediate and extended family members)
- Family history: [describe family history of ADHD, mental health, or neurodivergent traits] (only mention if relevant family history is noted)
- School and Year level: [describe where they go to school, their year level] (for children only, include the current school and academic year)
- Pregnancy and Birth History: [describe information about client’s pregnancy and birth history. Especially note any health concerns or predisposing factors] (only include if explicitly mentioned by the client or caregiver)
- Childhood History: [describe any predisposing factors in childhood or any relevant history/trauma. Only describe ADHD symptoms in categories below] (summarize relevant childhood history, excluding symptoms already mentioned below)
- Education and work history: [describe for adults only] (include educational and employment background for adult clients)
A) Inattention
(For each criterion, only describe behaviours or symptoms if mentioned or observed in the session. Do not repeat the same observations in multiple criteria.)
1) Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
2) Often has difficulty sustaining attention in tasks or play activities
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
3) Often does not seem to listen when spoken to directly
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
4) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
5) Often has difficulty organizing tasks and activities
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
6) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
7) Often loses things necessary for tasks or activities
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
8) Is often easily distracted by extraneous stimuli
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
9) Is often forgetful in daily activities
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
B) Hyperactivity and Impulsivity
(For each criterion, only describe behaviours or symptoms if mentioned or observed in the session. Do not repeat the same observations in multiple criteria.)
1) Often fidgets with or taps hands or feet or squirms in seat
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
2) Often leaves seat in situations when remaining seated is expected
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
3) Often runs about or climbs in situations where it is inappropriate
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
4) Often unable to play or engage in leisure activities quietly
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
5) Is often “on the go,” acting as if “driven by a motor”
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
6) Often talks excessively
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
7) Often blurts out an answer before a question has been completed
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
8) Often has difficulty waiting his or her turn
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
9) Often interrupts or intrudes on others
- [describe any reported behaviours or symptoms consistent with the above diagnostic criteria]
Symptoms interfere with or reduce the quality of:
- Social Functioning: [describe how functional skills or distress is caused by symptoms of inattention or hyperactivity] (only include observations related to social impairments)
- Academic Functioning: [describe how functional skills or distress is caused by symptoms of inattention or hyperactivity] (only include observations related to academic challenges)
- Occupational Functioning: [describe how functional skills or distress is caused by symptoms of inattention or hyperactivity] (only include if occupational functioning is impacted)
- Home Functioning: [describe how functional skills or distress is caused by symptoms of inattention or hyperactivity] (focus on impairments or distress in the home environment)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank. Use as many bullet points as needed to capture all the relevant information from the transcript.)
