The Simple Guide to Write SOAP Notes for ADHD

SOAP Notes for ADHD | Complete Documentation Guide with AI

Most ADHD SOAP notes I've seen read like grocery lists of symptoms.

'Patient exhibits hyperactivity, inattention, impulsivity.' Check, check, check.

But here's the thing...

This kind of documentation doesn't help anyone.

Not the patient, not the treatment team, and definitely not you when you're trying to track progress six months down the line.

Quick tip: I fixed SOAP Notes and built a tool that does this for the population. All you have to do is record and you have a standard soap note for ADHD. Save your sweat.

How Things Changed

SOAP notes weren't always the standard.

Before the 1960s, medical documentation was basically organized chaos.

Narrative notes that mixed observations with hunches, patient complaints with clinical findings, all jumbled together.

Dr. Lawrence Weed changed that when he introduced the SOAP format as part of his Problem-Oriented Medical Record system.

His idea was simple: structure clinical thinking by separating Subjective information (what patients report), Objective data (what you can measure or observe), Assessment (your clinical conclusions), and Plan (next steps).

It worked so well that it spread throughout healthcare and became the foundation for how we document patient encounters today.

The format forces clarity, ensures completeness, and makes it easier for other providers to follow your reasoning.

The Right Approach to Write SOAP Notes for ADHD

I'll say in 4 words: Head over to soapnotes.doctor. It's that simple.

The team at soapnotes.doctor has spent months building simplicity, speed, accuracy, and most importantly security for the medical industry.

We launched a week ago and it has been "reviews" galore.

If you're still second-guessing, you may still be in love with hectic documentation.

To get started:

1. Sign up
2. Use the "start recording" button
3. Use the "save session" button when you're done
4. Voila

Now for whatever reason you need to edit, you can easily do that using the tailorr button.

Want to use a different medical pattern? Perhaps your practice uses bullet points over paragraphs.

We built the tailorr feature for this.

Three-Layer ADHD Documentation System

One of the things I love doing outside the hood is systemizing, and it's the best way to approach SOAP notes if you insist on doing them the hard way, the manual way.

Here's the system that'll keep you from losing your mind.

I call it the Three-Layer SOAP system.

Stick with me.

Layer 1: Build Your ADHD-Specific Template Before Anyone Shows Up

Stop reinventing the wheel every time you see an ADHD patient.

There's a reason templates have always existed. You could have all the writing prowess the world ever needs, but lose it on the day you're not in your best mood.

With a template, you don't really have a choice. You have a template.

It's akin to Google maps. A good template is Google's map to your soap notes.

So create a framework that captures what actually matters in ADHD treatment.

For instance...

Subjective:

• Client reports current medication effects: [specific changes since last visit]
• Primary concern today: [the thing they circled back to three times]
• Executive function check-in: [organization, time management, task completion]
• Emotional regulation: [frustration tolerance, mood swings, rejection sensitivity]
• Direct quote: [their exact words that capture the core struggle]

Objective:

Make a targeted observation checklist. Did they interrupt you? How many times did they get up?

Could they maintain focus during the explanation of the treatment plan? Were they hyperfocused on one topic or jumping between ideas? Any visible anxiety or emotional dysregulation?

Assessment:

What's the real story here? Are stimulants helping with attention but creating anxiety? Is the hyperactivity masking depression?

Any signs that this isn't just ADHD? Connect the dots between symptoms and functional impairment.

Layer 2: Create ADHD-Smart Shorthand

Now that you've got your template, the last thing you want to do is start documentation right away.

Don't try to capture every fidget and topic change in a session, even if you're Socrates with a stethoscope.

Keep your notes simple at the start of things. Use abbreviations where you can. Summarize when you can. At this point, your goal should be to focus on your patient case.

Lastly, your abbreviations need to capture ADHD-specific patterns:

• "Attn→3min" means attention span maxed out at three minutes
• "Stim++" means medication is clearly working with visible improvement
• "EF fail" means executive functioning breakdown (forgot homework, lost keys, etc.)
• "RSD trigger" means rejection sensitivity kicked in during session
• "Hyper→shutdown" means they went from bouncing off walls to completely shut down

The key is consistency. Don't write "hyperactive" one week and "hyper" the next, or you'll be playing detective with your own notes later.

Layer 3: The Immediate Expansion Process (Where ADHD Documentation Lives or Dies)

The critical window for ADHD documentation happens in the minutes immediately following each session.

ADHD presentations are usually complex. Patients often jump between topics, present overlapping symptoms, and share crucial details in passing remarks.

If you don't capture these nuances while they're fresh, you'll lose the clinical threads that you've made and may end up in the same loop of being drowned in documentation.

Typical documentation debt...

As soon as your patient leaves, take five to seven minutes to expand your shorthand into comprehensive notes.

You do this as early as you can so you reinstate your shorthand systems and don't forget any weird ones you may have used.

Subjective

Your shorthand "Attn→3min" becomes "Patient demonstrated sustained attention for approximately 3 minutes before becoming distracted by external stimuli, consistent with reported medication wearing off by afternoon."

Your note "EF fail" expands to "Patient reported forgetting to submit work assignment despite completing it, indicating continued executive function challenges with task completion and follow-through."

Objective

This is where you add the clinical reasoning that connects your observations to treatment goals.

Explain why certain topics emerged during the session and how they relate to the patient's overall ADHD management.

If you shifted from discussing medication adherence to exploring workplace accommodations, document that connection.

If family dynamics surfaced while discussing school performance, note how these areas intersect with ADHD symptom management.

Assessment

Your Assessment section should reflect sophisticated clinical thinking about ADHD presentation, not surface-level symptom tracking.

Document how current symptoms impact daily functioning, how medication effects are manifesting across different settings, and what patterns you're observing in their coping strategies.

Plan

The Plan section requires similar specificity.

Rather than generic statements, document targeted interventions based on your session observations.

If you're adjusting behavioral strategies based on new workplace challenges, specify that.

If you're coordinating with their psychiatrist about sleep issues affecting medication efficacy, include those details.

This immediate expansion process ensures your documentation captures the full complexity of ADHD presentation while your clinical observations are still accurate and complete.