Complete Guide to ADHD SOAP Note Examples for Mental Health Professionals

If you've ever struggled to document ADHD sessions in a way that satisfies insurance requirements while actually being useful, this guide is for you.

I've talked to countless therapists, psychiatrists, and counselors who spend hours after their last appointment trying to get their notes "just right" for insurance reviewers.

The reality is that ADHD documentation has specific requirements that go beyond basic therapy notes.

Insurance companies want to see measurable progress, clear functional impairments, and evidence that treatment is medically necessary.

That's exactly why I built SOAP Notes Doctor to handle the heavy lifting of documentation while you focus on patient care.

In this article, I'll show you exactly how to write ADHD SOAP notes that meet insurance standards, with real examples you can use as templates.

🧾 What SOAP Notes Really Are (And Why They Matter for ADHD)

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose.

They were introduced in the 1960s by Dr. Lawrence Weed as part of the Problem-Oriented Medical Record (POMR).

His goal was straightforward: create a documentation system that anyone reviewing a chart could understand quickly and completely.

For ADHD specifically, SOAP notes are critical because they demonstrate:

• Ongoing symptoms and functional impairment
• Response to treatment interventions
• Medical necessity for continued care
• Progress toward measurable goals

SOAP stands for:

• S — Subjective: What the patient (or parent/guardian) reports about symptoms, challenges, and functioning.
• O — Objective: What you observe during the session, including behavioral observations, test results, and measurable data.
• A — Assessment: Your clinical interpretation, including diagnosis, severity, and progress evaluation.
• P — Plan: Your treatment plan going forward, including interventions, medications, follow-up, and goals.

This structure keeps your documentation organized, defensible, and insurance-friendly.

You're not just recording what happened you're building a clinical narrative that justifies ongoing treatment.

How You Can Approach ADHD SOAP Notes

There's no single correct method for writing ADHD SOAP notes, but some approaches work better than others depending on your practice.

Here are two main approaches I've seen work well.

1. Traditional, Manual Documentation

This is the classic method: typing out each section after each session. It works if you have strong clinical writing skills and consistent time built into your schedule. The challenge is it's time-consuming, and notes can become inconsistent across different sessions or providers in group practices.

2. SOAP Notes Doctor

You record your session or dictate your observations, and the tool automatically structures everything into proper SOAP format. It maintains consistency, saves hours of documentation time, and ensures you never miss critical components that insurance companies look for.

How to Make ADHD SOAP Notes Faster

One of the biggest complaints I hear from mental health professionals is how documentation eats into their personal time.

You've just finished back-to-back sessions with challenging cases, and instead of decompressing or preparing for tomorrow, you're stuck typing detailed notes for insurance.

The pressure is real: make them too brief and you risk denials; make them too detailed and you've just added hours to your week.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your session or dictate key observations
✅ Generate properly formatted SOAP notes instantly
✅ Get your evenings and weekends back

With soapnotes.doctor, you can record during or right after a session, add rough notes about specific observations, or even upload audio later. The system converts everything into insurance-compliant SOAP notes automatically.

You still get the clinical accuracy and thoroughness that insurance companies require, but without manually typing every detail.

Maybe you observed specific behaviors?

Fidgeting, difficulty maintaining eye contact, interrupted three times during conversation, parent reports medication compliance issues.

Use the tailorr feature to add them. Keep it raw and unpolished soapnotes.doctor handles the rest.

Example 1: Child with ADHD, Combined Type

Patient: 9-year-old male
Chief Complaint: Continued difficulties with attention and hyperactivity at school and home.
Visit: Follow-up, 6 weeks post-medication adjustment.

S – Subjective:

Parent reports child's teacher sent home progress notes indicating improved focus during morning classes but continued difficulty completing assignments independently. Child states he "forgets what to do" even when instructions are repeated. Parent reports bedtime routine has improved since last visit, with child falling asleep within 30 minutes (previously 1+ hour). Child endorses feeling "less bouncy" at school. Reports no side effects from current medication regimen.

O – Objective:

Patient fidgeted moderately during session but was able to remain seated for 25-minute interview (improvement from 15 minutes at previous visit). Made appropriate eye contact approximately 60% of the time. Interrupted conversation 4 times (down from 8–10 times in previous sessions). Vanderbilt ADHD Rating Scale completed by parent shows scores of 2.4 for inattention (previously 2.8) and 1.9 for hyperactivity/impulsivity (previously 2.5). Speech clear and coherent. No signs of depression or anxiety noted.

A – Assessment:

ADHD, Combined Type (F90.2). Patient showing gradual improvement in both inattentive and hyperactive symptoms following medication adjustment. Functional impairment persists in academic setting, particularly with task completion and following multi-step directions. Sleep improvement suggests medication timing is appropriate. Continued treatment medically necessary to address ongoing functional impairments in school performance and social interactions.

P – Plan:

Continue current medication regimen (Methylphenidate ER 18mg daily). Provided parent with behavioral strategies for homework completion, including visual schedules and timed work intervals. Coordinated with school counselor to implement preferential seating and extended time for assignments per 504 plan. Parent to complete weekly behavior tracking log. Follow-up appointment in 4 weeks to reassess medication efficacy and academic progress. Will consider referral to educational therapist if assignment completion does not improve within 8 weeks.

Example 2: Adult with ADHD, Predominantly Inattentive Type

Patient: 28-year-old female
Chief Complaint: Executive dysfunction impacting work performance and daily life management.
Visit: Initial medication management visit following diagnosis.

S – Subjective:

Patient reports long-standing difficulties with organization, time management, and task completion that have worsened since starting new job 6 months ago. Describes missing deadlines at work despite working late hours, losing important documents, and forgetting appointments even with calendar reminders. Reports feeling "mentally exhausted" by end of workday. States she has always struggled with these issues but "could get by" in previous, less demanding positions. Denies significant hyperactivity or impulsivity. Endorses mild anxiety related to work performance concerns. Sleep generally adequate (6–7 hours nightly). No substance use. Previous trial of therapy alone provided limited benefit for executive function difficulties.

O – Objective:

Patient arrived 10 minutes late to appointment, apologetic, stated she "forgot to leave early for traffic." Presentation neat and appropriate. Speech normal rate and tone. Mood appears euthymic but somewhat anxious when discussing work challenges. Affect congruent with mood. Thought process logical and goal-directed but tangential at times, required gentle redirection to stay on topic. Adult ADHD Self-Report Scale (ASRS) score of 18/24, indicating clinically significant symptoms. Conners' Adult ADHD Rating Scale completed: T-score of 68 for Inattention/Memory Problems, 52 for Hyperactivity/Restlessness. Denies suicidal ideation, homicidal ideation, or psychotic symptoms.

A – Assessment:

ADHD, Predominantly Inattentive Type (F90.0), moderate severity. Patient presents with significant functional impairment in occupational setting and activities of daily living. Symptoms consistent with long-standing pattern dating to childhood, though not formally diagnosed until now. Mild anxiety appears secondary to ADHD-related difficulties and work stress. Patient is appropriate candidate for pharmacological intervention given severity of impairment and limited response to behavioral interventions alone.

P – Plan:

Initiate trial of Amphetamine/Dextroamphetamine ER 10mg once daily in morning with breakfast. Reviewed medication risks, benefits, and common side effects including appetite suppression, insomnia, increased heart rate, and potential for misuse. Patient verbalized understanding and provided informed consent. Baseline vital signs: BP 118/76, HR 72. Provided psychoeducation on ADHD in adults and strategies for improving executive function, including use of external organizational systems, breaking large tasks into smaller steps, and time-blocking techniques. Patient to monitor response to medication using daily symptom tracking sheet. Follow-up visit in 2 weeks to assess medication response and side effects, with potential dose adjustment. Recommended cognitive-behavioral therapy with ADHD-specialized therapist to develop compensatory strategies; provided referral list.

Example 3: Adolescent with ADHD and Comorbid Anxiety

Patient: 15-year-old female
Chief Complaint: Difficulty focusing on schoolwork, increased anxiety about grades.
Visit: Monthly medication management and therapy check-in.

S – Subjective:

Patient reports current medication (Atomoxetine 40mg) is "helping some" with concentration but still struggles to complete homework assignments, particularly in math class. States anxiety about upcoming exams is affecting sleep (waking 2–3 times per night, difficulty falling back asleep). Parent confirms patient seems more focused during structured activities but becomes overwhelmed when faced with multiple assignments. Patient denies depressive symptoms. Reports using deep breathing techniques learned in therapy "sometimes" but forgets when stressed. No suicidal thoughts or self-harm behaviors. Appetite normal.

O – Objective:

Patient presented with good hygiene and appropriate dress. Maintained adequate eye contact. Mood self-described as "stressed." Affect anxious but brightened when discussing upcoming school concert. Speech normal rate, slightly pressured when discussing academic concerns. No psychomotor agitation observed. GAD-7 score: 12 (moderate anxiety, increased from score of 8 one month ago). Connor's 3 Self-Report completed: T-score 62 for Inattention, 48 for Hyperactivity. Reports medication compliance at approximately 90% (missed 2–3 doses over past month). Vital signs stable: BP 112/68, HR 78, Wt 128 lbs (stable).

A – Assessment:

ADHD, Predominantly Inattentive Type (F90.0), currently stable on medication. Generalized Anxiety Disorder (F41.1), worsening. Patient showing adequate response to ADHD medication with some residual inattentive symptoms. Anxiety appears to be exacerbating ADHD symptoms and interfering with academic performance. Increased anxiety may be situational (related to exam period) but warrants monitoring and intervention. Patient would benefit from increased use of coping skills and possible therapy intensification.

P – Plan:

Continue Atomoxetine 40mg daily. Will not adjust ADHD medication at this time given adequate response and recent anxiety exacerbation. Reviewed importance of medication compliance; patient committed to setting daily alarm reminder. Addressed anxiety management: reviewed CBT techniques including cognitive restructuring of catastrophic thinking about grades, progressive muscle relaxation for sleep difficulties, and scheduled worry time. Provided worksheet on breaking down study tasks into manageable segments. Recommended increasing therapy frequency from monthly to biweekly for next 6 weeks to address anxiety symptoms. Parent to help establish consistent bedtime routine and limit screen time 1 hour before bed. Patient to track sleep quality, anxiety levels, and homework completion for next visit. Follow-up in 3 weeks to reassess anxiety symptoms and consider need for anxiolytic medication if symptoms do not improve with increased therapy and behavioral interventions. Will coordinate with school counselor regarding exam accommodations if needed.

Key Components Insurance Companies Look For in ADHD SOAP Notes

When reviewing your ADHD documentation, insurance companies specifically want to see:

1. Clear Functional Impairment

Don't just say "patient has trouble focusing." Describe how ADHD impacts daily life: academic performance, work productivity, relationships, or activities of daily living.

2. Measurable Progress (or Lack Thereof)

Use standardized rating scales (Vanderbilt, Conners, ASRS) and compare scores over time. Quantify improvements: "interrupting decreased from 10 times per session to 4 times."

3. Medical Necessity

Explain why continued treatment is necessary. If symptoms are improving, document remaining impairments. If symptoms aren't improving, explain why treatment plan adjustment is warranted.

4. Treatment Plan Changes

Document when and why you adjust medications, increase therapy frequency, or add new interventions. This shows active clinical management.

5. Coordination of Care

Note communication with schools, other providers, or family members. This demonstrates comprehensive care.

6. Safety Monitoring

For stimulant medications, document vital signs, growth parameters in children, and screening for misuse or diversion.

Common Mistakes to Avoid

Being Too Vague: "Patient doing better" doesn't cut it. Specify what improved and by how much.

Forgetting Baseline Comparisons: Always reference previous symptoms or scores to show trajectory.

Neglecting Functional Impact: Clinical symptoms matter less to insurance than real-world impairment.

Skipping Objective Measures: Use rating scales regularly. Subjective reports alone aren't enough.

Copy-Pasting Previous Notes: Insurance reviewers notice. Each note should reflect that session specifically.

Final Thoughts

ADHD SOAP notes don't need to be overwhelming.

They need to be thorough, yes, but they don't need to consume your life.

The key is having a system that captures the right information without making you feel like a secretary instead of a clinician.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that serves your patient and satisfies insurance requirements.

Your time is better spent treating patients than fighting with documentation.

That's exactly why we built this tool.

Try it out, see how much time you get back, and let me know what you think.

---

Ready to simplify your ADHD documentation?
Visit soapnotes.doctor and get your first notes generated in minutes.