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Psychiatry — ADHD follow-up

ADHD medication management

reference-draftsample-librarycuratedquality claim pdsqi
ADHDstimulantworklibrary

Subjective

Client: Better mornings. Still crashes at 3pm. Missed two deadlines. Client: Eating less lunch. Sleep ok if I skip late caffeine. Client: No.

Objective

Observed findings and measures per transcript.

Assessment

Clinical formulation supports continued structured outpatient care (ADHD medication management).

Plan

Psychiatrist: Continue methylphenidate XR, add afternoon booster trial, CBT skills for planning, follow-up in six weeks.

Source transcript

Psychiatrist: Focus at work on current dose?
Client: Better mornings. Still crashes at 3pm. Missed two deadlines.
Psychiatrist: Appetite and sleep?
Client: Eating less lunch. Sleep ok if I skip late caffeine.
Psychiatrist: Heart rate / BP from PCP were normal. Any SI?
Client: No.
Psychiatrist: Continue methylphenidate XR, add afternoon booster trial, CBT skills for planning, follow-up in six weeks.