Current Medication:
[Describe the patient's current medication regimen for ADHD, including the name of each medication, dosage, frequency, and route of administration, along with any other medications, supplements, or over-the-counter remedies they are currently taking. Also include details on adherence, any recent changes in dosage or medication type, and the rationale for these changes, if provided.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Response to Medication:
[Provide a comprehensive assessment of the patient's response to their current ADHD medication, detailing the perceived efficacy in managing ADHD symptoms such as inattention, hyperactivity, and impulsivity. Include specific examples or reported improvements in academic, occupational, or social functioning, as well as any areas where the medication's effectiveness may be limited.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Current Symptoms:
[Detail the patient's current ADHD symptoms, irrespective of medication, providing specific examples of how these symptoms manifest in their daily life. This should encompass symptoms of inattention (e.g., difficulty sustaining attention, organizational challenges), hyperactivity (e.g., restlessness, fidgeting), and impulsivity (e.g., interrupting, difficulty waiting). Include information on symptom severity, frequency, and impact on various life domains.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Side Effects:
[Document any experienced side effects associated with the ADHD medication, providing specific details such as the nature of the side effect, its onset, duration, severity, and any actions taken to mitigate it. This should cover common side effects like appetite suppression, sleep disturbance, gastrointestinal issues, and cardiovascular effects, as well as any other adverse reactions reported.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Physical Monitoring for ADHD Medications:
[Record all physical parameters routinely assessed in the context of ADHD medication. This includes the patient's current weight, blood pressure (systolic and diastolic), heart rate, and details regarding sleep patterns (e.g., duration, quality, difficulties with initiation or maintenance), and appetite (e.g., changes in intake, impact on weight). Include any other relevant physical observations or patient-reported physical symptoms.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Duration of Action:
[Describe the perceived duration of action of the ADHD medication, specifically noting the approximate time when the medication's effects are reported to wear off. Include patient observations regarding the return of symptoms or a decline in medication efficacy at certain points in the day, and any impact this has on their daily functioning.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Investigations:
[Detail any investigations conducted or discussed, including but not limited to the administration or results of the Adult ADHD Self-Report Scale (ASRS). Also include any other psychological assessments, blood tests, or diagnostic procedures undertaken or considered, along with their findings and relevance to the patient's ADHD management.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Risk Assessment:
[Provide a comprehensive assessment of risks, including any current or historical psychiatric comorbidities, substance use, suicidal ideation or attempts, self-harm, impulsivity-related risks, or any other psychosocial stressors that may impact the patient's well-being or ADHD management. Include an evaluation of protective factors and a plan for risk mitigation.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Mental State Examination:
[Document the findings of the mental state examination, including observations regarding the patient's appearance, behavior, speech, mood, affect, thought form and content, perception, cognitive function (e.g., attention, concentration, memory), insight, and judgment.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Treatment Plan:
[Outline the comprehensive treatment plan, including any adjustments to medication (e.g., dosage changes, timing, medication switches), non-pharmacological interventions (e.g., psychotherapy, coaching, lifestyle modifications), educational strategies, and referrals to other specialists. Include goals for treatment, follow-up arrangements, and any specific advice or recommendations provided to the patient.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(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 included 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 omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)