For clinicians using NovoNote who interview an adult suspected of having attention deficit hyperactivity disorder (ADHD), this template provides a concise summary of information required to assist with making an informed diagnosis based on DSM-5-TR (and ICD-11) criteria.
Clinicians are encouraged to consult the DSM-5-TR or ICD-11 to check criteria against the contents of this note before making a diagnosis.
Referral Reason
Describe the client’s reasons for seeking the attention deficit hyperactivity disorder assessment. Describe the symptoms, behaviours, events, and situations that have led to the assessment. Include onset, changes over time, and impact on daily functioning.
People Present
List the person or people in attendance during the interview, other than the clinician. Identify the client and state relationships.
Mental Status Examination (MSE)
Summarise the client’s presentation using standard MSE domains: Appearance, Behaviour, Speech, Mood and Affect, Thought Process, Thought Content, Perception, Cognition, and Insight and Judgment.
BACKGROUND
Personal and Developmental History
Previous Assessments
Describe results of any previous psychological, cognitive, or medical testing.
Medical History
Describe any previous medical, psychiatric, or neurodevelopmental diagnoses.
Current Medications
Describe all current medications the client is taking, including doses, frequencies, and reasons.
Other Previous Treatment
Describe any previous non-medication interventions the client has participated in.
DSM-5-TR CRITERIA A1
Inattention – five or more of the following are required
A Describe if the client often fails to give close attention to details or makes careless mistakes.
B Describe if the client often has difficulty sustaining attention in tasks or leisure activities.
C Describe if the client often does not seem to listen when spoken to directly.
D Describe if the client often does not follow through on instructions and fails to finish tasks.
E Describe if the client often has difficulty organizing tasks and activities.
F Describe if the client often avoids, dislikes, or is reluctant to engage in tasks requiring sustained mental effort.
G Describe if the client often loses things necessary for tasks or activities.
H Describe if the client is often easily distracted by extraneous stimuli.
I Describe if the client is often forgetful in daily activities.
DSM-5-TR CRITERIA A2
Hyperactivity and Impulsivity – five or more of the following are required
A Describe if the client often fidgets with, or taps hands or feet, or squirms in seat.
B Describe if the client often leaves seat in situations when remaining seated is expected.
C Describe if the client often runs about or climbs in inappropriate situations or feels restless.
D Describe if the client is often unable to play or engage in leisure activities quietly.
E Describe if the client is often “on the go,” acting as if “driven by a motor.”
F Describe if the client often talks excessively.
G Describe if the client often blurts out answers before questions have been completed.
H Describe if the client often has difficulty waiting their turn.
I Describe if the client often interrupts or intrudes on others.
DSM-5-TR CRITERIA B
Describe if several inattentive or hyperactive-impulsive symptoms were present prior to age 12.
DSM-5-TR CRITERIA C
Describe if several inattentive or hyperactive-impulsive symptoms are present in two or more settings.
DSM-5-TR CRITERIA D
Describe if there is clear evidence that symptoms interfere with or reduce quality of functioning.
DSM-5-TR CRITERIA E
Print this statement: Before applying a diagnosis of ADHD, the clinician must ensure that the symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder.
Strengths, Interests and Hobbies
Describe the client’s strengths, interests, hobbies, unique skills, and positive personality traits.
Client Goals
Describe how the client would like to improve and what they believe would help them flourish.
Clinician Observations, Notes, and Diagnostic Impressions
Describe any other observations or notes made by the clinician during the interview. This may include information related to their assessment, comments on anything that the client has said, comments in response to anything the client has done, or any other clinically relevant information provided by the clinician in the transcript. If provided, describe the clinician’s diagnosis, explanation of the client’s cognitive or neurodivergent profile, and observations about comorbidities, differential diagnosis, and co-occurring traits such as anxiety, trauma, executive dysfunction.
Risk
Based on clinician comments in the transcript, make a risk assessment in a statement (e.g., suicidal or homicidal ideation, self-harm, or harm to others, if any). Include any information related to past suicide attempts or past self-harming behaviour. Include any information about psychosocial stressors contributing to the level of risk. Describe any risk for social isolation. Describe any risk for being the victim or perpetrator of bullying, and include any stated history of bullying. Describe any protective factors that mitigate the risk.
Next Steps
Summary
Provide a brief paragraph summary of the appointment with the client.
Referral Reason
Ms. Johnson (34) was referred for ADHD assessment due to difficulties with concentration, organisation, and task completion. These issues have intensified since her promotion to a management role. She reports missing deadlines, forgetting appointments, and leaving household tasks unfinished, causing strain in her marriage and anxiety about work performance.
People Present
Mental Status Examination (MSE)
Ms. Johnson presented as well-groomed with intermittent eye contact, notable psychomotor restlessness, and rapid, pressured speech with frequent topic shifts. Her self-described “anxious and overwhelmed” mood aligned with her observed affect that ranged from worried to frustrated when discussing impacts on her marriage and career.
BACKGROUND
Personal and Developmental History
Ms. Johnson reports normal early development though was described as “always on the go” as a child. School records note she was “bright but chatty” with “difficulty staying in her seat.” She struggled with handwriting and showed underachievement relative to her abilities, excelling in subjects of interest but performing poorly in those requiring sustained attention.
She grew up in a supportive two-parent home and currently lives with her husband of six years.
No significant trauma history was reported. Family history includes ADHD in her father and brother, and anxiety disorders in maternal relatives. Currently employed as a marketing manager for 14 months, she previously worked in a less administratively demanding role. She demonstrates insight into her symptoms but feels frustrated by inability to overcome challenges despite effort.
Previous Assessments
Psychoeducational testing in 2011 by Dr. Chen indicated above-average intelligence (FSIQ 118) with discrepancies between verbal comprehension (superior) and processing speed (low average). Testing noted attention challenges but did not result in formal ADHD diagnosis.
Medical History
Diagnosed with Generalised Anxiety Disorder in 2018 by her GP, Dr. Williams.
Current Medications
Escitalopram 10mg daily for anxiety, multivitamin, and oral contraceptives (Yaz).
Other Previous Treatment
CBT for anxiety with Dr. Lee (20 sessions, 2018-2019), which helped anxiety but didn’t adequately address organisational difficulties.
DSM-5-TR CRITERIA A1
Inattention – five or more of the following are required
A Makes careless mistakes in work documentation despite proofreading, recently submitting a client proposal with incorrect figures.
B Difficulty sustaining attention during meetings beyond 30 minutes, often “zoning out” during calls and struggling to complete TV episodes or books.
C Frequently “tunes out” during conversations with her husband, requiring repeated information. During assessment, needed questions repeated despite absence of distractions.
D Fails to complete multi-step assignments without reminders. Has numerous unfinished home projects and recently completed only partial sections of a required report.
E Pronounced organisational difficulties at work and home, including unsorted files, multiple lost to-do lists, missed meetings, and delayed bill payments despite organisational attempts.
F Avoids paperwork and detailed reading, delaying tax lodgements for three years and delegating report writing when possible.
G Loses phone weekly and keys daily despite tracking systems. Lost two company laptops in three months and was unable to locate her planner during our session.
H Highly distractible by email notifications, ambient conversations, and minor environmental sounds, describing herself as “at the mercy of any stimulus.”
I Regularly forgets appointments despite reminders, misses bill payments, and leaves essential items at home, causing significant frustration for her husband.
DSM-5-TR CRITERIA A2
Hyperactivity and Impulsivity – five or more of the following are required
A Displayed continuous fidgeting during assessment, including foot tapping, pen clicking, hair twirling, and frequent repositioning.
B Difficulty remaining seated during work meetings and meals at home, frequently getting up for unnecessary reasons.
C Information related to this diagnostic criterion not found in the transcript.
D Information related to this diagnostic criterion not found in the transcript.
E Describes herself as constantly “on the go,” taking on multiple simultaneous projects and unable to relax even during holidays.
F Speaks rapidly with excessive detail, elaborating far beyond necessary during assessment and in personal conversations.
G Completes others’ sentences and answers questions before fully asked, causing tension in workplace meetings.
H Significant impatience in queues and traffic, frequently changing lanes or lines. Sends multiple follow-up emails within hours of initial communication.
I Frequently interrupts conversations in work and social settings, causing tension with friends and receiving feedback about dominating team discussions.
DSM-5-TR CRITERIA B
Symptoms present since early primary school, with consistent teacher notes about difficulties staying seated, talking out of turn, and completing assignments. Teachers suggested ADHD evaluation at age 8, though no assessment was conducted.
DSM-5-TR CRITERIA C
Attention and hyperactivity-impulsivity difficulties evident across workplace (missed deadlines, careless errors), home (incomplete chores, lost items), and social situations (interrupted conversations, difficulty maintaining attention).
DSM-5-TR CRITERIA D
Symptoms significantly impact occupational functioning (performance concerns), social functioning (strained marriage and friendships), and daily functioning (organisational challenges leading to missed appointments and incomplete tasks).
DSM-5-TR CRITERIA E
Before applying a diagnosis of ADHD, the clinician must ensure that the symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder such as mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal.
Strengths, Interests and Hobbies
Ms. Johnson shows exceptional creative thinking and idea generation, strong verbal communication skills, and resilience in developing compensatory strategies. Her employer values her innovative solutions and “outside the box” thinking. Interests include photography, bushwalking, and cooking, with particular enjoyment of activities involving movement and creativity.
Client Goals
Ms. Johnson aims to improve task completion, reduce careless errors, meet deadlines consistently, better manage household responsibilities, and reduce anxiety associated with organisational difficulties. She hopes addressing attention difficulties will allow her to utilise creative strengths while minimising negative impacts on her professional and personal life.
Clinician Observations, Notes, and Diagnostic Impressions
Ms. Johnson presents with a pattern consistent with ADHD, Combined Presentation, with childhood onset and significant impairment across multiple domains. Her comorbid Generalised Anxiety Disorder appears secondary to her attention difficulties. Strong verbal abilities likely served as compensatory factors, contributing to delayed diagnosis. Executive function deficits are particularly evident in planning, organisation, and working memory. Her insight is good, and she appears highly motivated to improve functioning.
Risk
Ms. Johnson denies current or past suicidal ideation or self-harm behaviours. Primary stressors include work performance concerns and marital strain. Protective factors include supportive family network, stable employment, financial security, and demonstrated resilience. Overall low risk for self-harm or harm to others.
Next Steps
Summary
Ms. Johnson presented for ADHD assessment due to persistent difficulties with attention, organisation, and task completion. Assessment revealed a pattern consistent with ADHD Combined Presentation, with childhood onset and significant functional impairment. Treatment plan includes medication evaluation, CBT, and occupational therapy assessment.
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