Even though we have done a comprehensive article on writing a SOAP note assignment, we reckon that it is wise to cover a few examples templates notwithstanding. Having looked at our database, we realized that most students struggle to handle assignments on ADHD SOAP notes.
ADHD short for Attention Deficit Hyperactivity Disorder is a common but often misunderstood condition that affects both children and adults. It can significantly affect an individual’s ability to focus, manage time, and regulate impulses, influencing their academic, professional, and social life. As a nursing student, you should understand ADHD. It is also important to learn how to properly document and manage it in clinical settings for effective and holistic patient-centered care. One of the most valuable tools in documenting patient interactions is the SOAP note, a structured method for recording subjective and objective findings, assessments, and treatment plans.
In this blog post, our expert nursing assignment writers walk you through the essential elements of the ADHD SOAP note template, offering a clear guide to help you create thorough and effective documentation. Whether you are encountering ADHD in a pediatric or adult setting, this guide will equip you with the knowledge to identify key symptoms, make accurate assessments, and develop comprehensive care plans. Let us dive in!
ADHD SOAP Note Template for Nursing Students
When assigned to write a SOAP note on ADHD, based on either a case study, case scenario, snippet, or an actual case, you need to understand how to document it. Here is a complete template of how to go about it.
1. Patient/Client Details
- Include the name of the patient, age, gender, and race.
2. SUBJECTIVE (S)
The Subjective section is based on the patient's description of their symptoms and experiences. It is important to listen carefully to the patient’s report of their condition and collect relevant information to help with diagnosis and treatment planning. In the case of a case study, read carefully and document what the client provides.
Key Information to Include in this section include:
- Chief complaint (CC): The reason the patient is seeking care. This is often a brief statement, such as “I can’t focus at work” or “I’m always restless.”
- History of Present Illness (HPI): Ask about the onset, duration, and frequency of symptoms like inattention, impulsivity, and hyperactivity. Understand how these symptoms affect their daily life, work, school, or relationships.
- Patient's feelings or concerns: Ask the patient how they feel about their symptoms and whether they have sought treatment before.
- Relevant family history: Ask if there is any family history of ADHD. Also, ask if there are other psychiatric conditions that may influence the diagnosis.
- Current medications and treatments: Ask if the patient is on any medications, including ADHD medications or treatments for other conditions.
Other things to include in this section include allergies, social history, family history,
Example Subjective:
- CC: "I can't focus at work, and I keep getting distracted in meetings."
- HPI: "I’ve had trouble staying focused for as long as I can remember. It has been worse in the last few months, and I feel like I cannot finish anything I start. My sister has ADHD, and I think I might have it too."
- Medications: Patient is not currently on medication for ADHD, but takes antidepressants (sertraline) for anxiety.
If you are writing from a case study, write it as if you are reporting the information that the patient or anybody accompanying them gave.
2. Review of Systems (ROS)
For a comprehensive SOAP Note, you need to introduce the ROS section since ADHD where various symptoms may overlap with other health issues. The ROS provides a structured way to gather information on the patient's overall health. It helps identify symptoms that may not have been directly mentioned in the Subjective section.
In the case of ADHD, the Review of Systems can help identify any coexisting conditions or symptoms that may affect the diagnosis or treatment plan. For example, a nurse may ask about mood disorders, sleep patterns, or physical health concerns that could be related to ADHD or complicate its management.
Here is a template for the ROS section:
General:
- Recent weight changes (gain/loss)?
- Fatigue, malaise, or weakness?
- Fever or chills?
- Night sweats?
Constitutionals:
- Any recent weight changes (gain or loss)?
- Any fatigue, fever, or chills?
- Any night sweats or difficulty maintaining normal energy levels?
- Overall health status: any feelings of illness or malaise?
Cardiovascular:
- Chest pain or palpitations?
- Shortness of breath or difficulty breathing with exertion?
- History of heart disease or hypertension?
Respiratory:
- Shortness of breath or wheezing?
- Cough or other respiratory symptoms?
- History of asthma or other lung conditions?
Gastrointestinal:
- Abdominal pain or discomfort?
- Nausea or vomiting?
- Changes in bowel habits (diarrhea, constipation)?
- Difficulty swallowing or loss of appetite?
Neurological:
- Headaches, dizziness, or vertigo?
- Numbness, tingling, or weakness?
- Seizures or tremors?
- Forgetfulness or difficulty concentrating (specific to ADHD)?
- Sensory disturbances?
Musculoskeletal:
- Joint pain or muscle stiffness?
- History of fractures or injuries?
- Muscle weakness or spasms?
Psychiatric:
- Anxiety, depression, or mood swings?
- Irritability or stress?
- Difficulty managing emotions?
- Feelings of restlessness, impulsivity, or hyperactivity (specific to ADHD)?
- History of psychiatric disorders (e.g., depression, anxiety, or bipolar disorder)?
Sleep:
- Difficulty falling or staying asleep?
- Insomnia or poor sleep quality?
- Restlessness during sleep (e.g., waking up frequently)?
- Snoring or gasping for air during sleep?
Endocrine:
- History of thyroid issues or diabetes?
- Increased thirst or hunger?
- Excessive sweating or heat/cold intolerance?
Hematologic:
- Easy bruising or bleeding?
- History of anemia or other blood disorders?
Allergic/Immunologic:
- Allergies to food, medications, or environmental factors?
- Frequent infections or immune system disorders?
Example of a Review of Systems for ADHD
- General: No significant weight changes, fever, or night sweats.
- Constitutionals: No recent weight changes, fever, or chills. Reports occasional fatigue, particularly in the afternoon. No significant night sweats or malaise. Denies any unexplained weight loss or chronic illness. Reports excessive hyperactivity, impulsivity, and inattention not accompanied by lack of comprehension. No difficulties in sleep.
- Cardiovascular: No chest pain, palpitations, or history of heart disease.
- HEENT: No dry eyes, itching, or pain. No photophobia. No hearing loss, no tinnitus, and no sneezing. No runny nose and no sore throat.
- Respiratory: No shortness of breath, wheezing, or coughing.
- Gastrointestinal: No abdominal pain, nausea, or changes in bowel habits.
- Genitourinary: No sense of burning sensation on urination and no polyuria.
- Neurological: No headaches, dizziness, or seizures. Occasional forgetfulness and distractibility, especially during work tasks.
- Musculoskeletal: No joint pain or stiffness.
- Psychiatric: Reports of chronic feelings of restlessness, anxiety, and irritability. Denies depressive symptoms but has difficulty managing stress.
- Sleep: Poor sleep quality; patient reports difficulty falling asleep and staying asleep due to racing thoughts.
- No excessive urination or excessive water intake. No excessive sweating or heat intolerance.
- Immunologic/allergic. Denies history of asthma or eczema or seasonal allergies.
3. OBJECTIVE (O)
The Objective section contains measurable data collected by the nurse. This includes physical findings, observations, and any diagnostic results. This section is vital for supporting the subjective reports from the patient and ensuring an accurate assessment.
Key Information to include here includes:
- Behavioral observations: Note any signs of inattention, impulsivity, or hyperactivity observed during the visit. For example, does the patient appear restless or have difficulty maintaining eye contact? Are they easily distracted?
- Vital signs: Record the patient’s blood pressure, heart rate, temperature, and weight, as they are important for overall health monitoring, especially when prescribing medications.
- Rating scales: Include any ADHD-specific assessment tools or rating scales you may have administered, such as the Conners Rating Scale, Vanderbilt Assessment Scale, or Adult ADHD Self-Report Scale (ASRS).
Example Objective:
- Behavioral Observations: Patient frequently fidgets during the interview, unable to sit still, and interrupts the conversation. Exhibits signs of anxiety (restlessness, rapid speech).
- Vitals: BP 120/78, HR 78 bpm, Temperature 98.6°F, Weight 170 lbs.
- Rating Scale: Conners’ Adult ADHD Rating Scale (CAARS) score of 26, suggesting moderate symptoms of ADHD.
4. Assessment (A)
In the Assessment section, the nurse synthesizes the subjective and objective findings to make a clinical judgment. This includes identifying the likely diagnosis, documenting the severity of the condition, and considering other possible diagnoses.
Key Information to Include:
- Diagnosis: Use the DSM-5 criteria to determine whether the patient meets the criteria for ADHD, which can be either primarily inattentive, hyperactive-impulsive, or combined presentation.
- Severity of symptoms: Evaluate how much the symptoms are affecting the patient's daily life, such as their ability to work, perform tasks, or maintain relationships.
- Differential diagnoses: Consider other possible conditions that may mimic ADHD, such as anxiety, depression, or learning disabilities, and determine if further assessment or referrals are necessary.
Example Assessment:
- Diagnosis: ADHD with Combined Presentation (Inattention and Hyperactivity/Impulsivity).
- Severity: Symptoms are affecting work performance and causing social distress.
- Differential Diagnosis: Ruling out generalized anxiety disorder and depression; further assessment needed to confirm ADHD diagnosis. You can also add Autism spectrum disorder or oppositional defiant disorder. Ensure to give a credible reference from a nursing journal or website.
5. Plan (P)
The Plan section outlines the next steps in managing the patient’s care. This includes treatment recommendations, referrals, patient education, and follow-up plans. As nursing students, this is your opportunity to apply evidence-based interventions and advocate for the patient.
Key Information to Include in this section of the SOAP note includes:
- Pharmacological treatment: Document any medications that may be prescribed for ADHD, such as stimulants (e.g., methylphenidate, amphetamines) or non-stimulants (e.g., atomoxetine).
- Non-pharmacological treatments: Recommend behavioral interventions, such as cognitive-behavioral therapy (CBT), skills training, or time management coaching.
- Patient education: Teach the patient and their family about ADHD, treatment options, and lifestyle changes that may help manage symptoms, such as regular exercise, sleep hygiene, and organizational strategies.
- Follow-up: Schedule a follow-up appointment to monitor the patient’s progress, review any medication side effects, and adjust the treatment plan as needed.
Example Plan:
- Medication: Start methylphenidate 10 mg daily; titrate to effect after one week. Monitor for side effects (e.g., insomnia, loss of appetite).
- Behavioral Therapy: Refer to CBT for organizational skills training and stress management.
- Patient Education: Provide information on ADHD, healthy coping strategies, and ADHD support groups.
- Follow-up: Return visit in 4 weeks to assess medication efficacy, side effects, and any concerns.
Related: How to write a Nursing Care Plan.
6. Health Promotion Section
After the SOAP Note section, some professors will ask you to cover a health promotion section. In this section, you should document the health promotion strategies for the patient with ADHD. You can organize your thoughts around:
Education and Awareness
- Educate the patient and family about ADHD symptoms, causes, and treatments.
- Include information about how ADHD affects daily life, relationships, and work or school performance.
- Provide resources on coping strategies for managing symptoms like distractibility, impulsivity, and hyperactivity.
- Discuss the importance of early intervention and treatment, including medication and therapy options.
Behavioral Therapy and Cognitive-Behavioral Interventions
- Recommend cognitive-behavioral therapy (CBT) to help the patient develop skills for emotional regulation, coping with stress, and improving executive function.
- Discuss the role of behavioral therapy in improving task completion, organizational skills, and social behavior.
- Encourage participation in skills training for managing time, setting goals, and maintaining focus.
Medication Management
- Discuss the potential use of ADHD medications (e.g., stimulants like methylphenidate or non-stimulants like atomoxetine) and their role in symptom management.
- Emphasize the importance of medication adherence and regular follow-ups to monitor effectiveness and side effects.
- Encourage the patient to communicate any concerns about side effects to the healthcare provider for medication adjustments.
Time Management and Organizational Skills
- Suggest practical strategies for improving time management, such as using planners, digital calendars, or reminders.
- Recommend breaking tasks into smaller steps and setting realistic, achievable goals.
- Emphasize the use of visual aids (e.g., to-do lists, sticky notes) to help stay organized and track progress.
Physical Activity and Exercise
- Advocate for regular physical activity, such as walking, running, or yoga, which has been shown to improve attention and reduce impulsivity.
- Recommend activities that are structured and engaging, such as team sports or martial arts, to enhance social skills and focus.
- Provide tips for incorporating physical activity into daily routines, such as taking breaks to walk or stretch during tasks.
Sleep Hygiene and Management
- Discuss the importance of maintaining a regular sleep schedule and creating a relaxing bedtime routine.
- Advise the patient to avoid caffeine, electronics, and stimulating activities before bedtime.
- If the patient experiences sleep disturbances, recommend further evaluation and management, such as addressing possible insomnia or sleep apnea.
Diet and Nutrition
- Promote a balanced diet that includes nutrient-dense foods like fruits, vegetables, lean proteins, and whole grains to support overall health.
- Discuss the possible role of certain nutrients (e.g., omega-3 fatty acids) in managing ADHD symptoms and improving brain function.
- Suggest regular meals and snacks to help maintain stable energy levels and avoid irritability due to fluctuating blood sugar.
Stress Management and Mindfulness
- Recommend mindfulness techniques, such as deep breathing, meditation, or yoga, to help reduce stress and improve focus.
- Encourage relaxation techniques to help the patient manage anxiety and frustration that can arise from ADHD symptoms.
- Provide resources for local mindfulness or stress reduction classes or apps.
Social Skills Training and Support
- Suggest participation in social skills training programs to improve interpersonal interactions and communication.
- Recommend joining ADHD support groups or group therapy for peer support and shared learning.
- Encourage the patient to build and maintain a supportive social network, including friends, family, or mentors.
Family and Social Support
- Involve family members in the care plan to ensure they understand ADHD and how they can support the patient’s treatment.
- Recommend family counseling or education to improve family dynamics and ensure effective communication within the household.
- Encourage involvement in community or online support groups where both patients and their families can learn and share coping strategies.
Advocacy and Legal Considerations
- Advise the patient on their rights under laws like the Americans with Disabilities Act (ADA), especially regarding accommodations at school or work.
- Provide information on how to request accommodations such as extended test-taking time or a quieter workspace.
- Encourage the patients to advocate for themselves and seek appropriate resources when needed.
Follow-Up and Monitoring
- Emphasize the importance of regular follow-up appointments to monitor symptom progression and treatment effectiveness.
- Discuss potential adjustments in the treatment plan as necessary (e.g., changes in medication, therapy).
- Schedule a follow-up to assess the impact of health promotion strategies on managing ADHD symptoms and overall well-being.
7. Reflection Section
The Reflection Section is an important component of many nursing assignments. It provides you with an opportunity to analyze their clinical experiences, learning process, and how they have applied theoretical knowledge in practice. For ADHD SOAP note assignment, you can reflect on their understanding of the disorder, how you approached the care plan, and the outcomes you expect of the recommended health promotion strategies. You can do this paragraph based on different reflective models that apply to nursing.
For this section, you can:
- Think about what you have learned about ADHD and how it affects patients across different life stages (childhood, adolescence, adulthood).
- Reflect on how ADHD presents in different patients and how treatment strategies may vary based on the individual’s symptoms, environment, and co-occurring conditions.
- Consider the theoretical knowledge you have gained in class and how it applies to your real-world clinical observations or experiences with ADHD.
- Reflect on your clinical experiences with ADHD patients, if applicable. What challenges did you encounter? How did you address those challenges in your care plan or through communication with patients or families?
- Consider how your interactions with the patient helped you understand their unique needs, including the role of education, support, and behavioral strategies in managing their ADHD.
- Reflect on how the health promotion strategies you proposed in the care plan are likely to affect the patient’s overall health and well-being. Consider the potential barriers to implementing these strategies and how you might overcome them.
- Discuss any concerns or uncertainties you have about your approach, and how you plan to address those in future care plans or real-life scenarios.
- Reflect on your own growth as a nursing student. How has this assignment or clinical experience helped you develop professionally?
- Discuss how you plan to further enhance your knowledge and skills in managing ADHD, including any specific areas of learning or patient care you want to focus on in future.
- Reflect on any ethical issues or cultural considerations you may need to be mindful of when working with ADHD patients. For instance, how might cultural background influence the way ADHD is perceived or treated by a patient or their family?
- Discuss how you will ensure that your care plan respects the patient's cultural, social, and personal preferences while promoting the best possible health outcomes.
Also Read this article to get more insights: How to write a Nursing Reflection Essay.
After the reflection model, ensure that you provide a list of references. Remember to use high-quality nursing peer-reviewed articles when writing the paper to provide justifications for your care plan. Check out our guide on the best resources to use in nursing assignments.
A Final Note
That is about all we have for writing a SOAP note on ADHD. The template with examples helps you meet and outdo the professor’s expectations of you. We understand that sometimes students struggle to find a balance and we have good news for you.
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