Adult ADHD SOAP Note Example for Therapists

In adult ADHD, psychological intervention usually focuses on strategies for organisation, planning and managing self-criticism, while medication is prescribed by another professional. The note needs to record progress with concrete results and make clear what falls to each professional.

The example below is fictional and educational. It is not a diagnostic assessment and does not replace professional judgement or applicable documentation requirements.

Fictional adult ADHD SOAP note example

Context: Sixth session of cognitive behavioural intervention for adult ADHD. The diagnosis was made by their psychiatrist, who also prescribes the medication.

Subjective: The person reports using the digital planner on five of the seven days and, for the first time in months, handing in a work report on time. They still find it hard to start long tasks and put them off until the last moment. They mention that their psychiatrist adjusted the dose two weeks ago and that they notice “more focus in the morning”, although they have less appetite at midday. They feel “a mess” when they forget things at home and argue with their partner about it.

Objective: Arrives five minutes late, with the planner open on their phone. Goes through the week's tasks fluently. During the session they change topic several times and pick up the thread again when this is pointed out. With help, they break a long work task down into four steps.

Assessment: Increasing use of the planner as an external organisation system, with a concrete result at work. Difficulty starting long tasks remains the main obstacle. The effects they report after the medication adjustment fall within their psychiatrist's follow-up, and it would be helpful to pass them on, including the loss of appetite. Self-criticism about forgetting things increases tension at home and may be a focus for work.

Plan: Apply the breakdown into steps to one long task and schedule the first step in the planner at a specific time. Try 25-minute work blocks with breaks. Encourage them to discuss with their psychiatrist the effects they notice from the medication. In future sessions, consider work on self-criticism and, if the person wishes, a session with their partner for psychoeducation about ADHD.

Why it is written this way

Medication and its effects appear as reported information and are referred to the professional who prescribes it. The note makes no recommendations about dosage and does not interpret the effects of the medication, because those decisions belong to the prescriber.

The diagnosis is attributed to whoever made it. That makes it clear where it comes from and who is responsible for each part of treatment.

Observations about attention in session are described as behaviour (changes topic, picks up the thread when this is pointed out) and not as confirmation of the diagnosis.

Progress is recorded with concrete results, such as the on-time submission or the number of days the planner was used. These are the data that make it possible to check whether the strategies are working.

The same session as a progress note

Sixth session. Used the digital planner on five of seven days and handed in work on time for the first time in months. Difficulty starting long tasks persists. Reports better concentration in the morning and less appetite after the medication adjustment prescribed by psychiatry; encouraged to discuss this with their psychiatrist. Intense self-criticism about forgetting things, with conflict in the relationship. Breaking a task into steps practised in session; 25-minute work blocks agreed.

Questions to use during review

• Is it clear who made the diagnosis and who prescribes the medication?
• Is information about medication recorded as reported, without assessing it outside your own role?
• Is progress recorded with concrete, comparable results?
• Are observations in session described as behaviour and not as diagnostic confirmation?
• Does the plan specify strategies that can be reviewed at the next session?

See the SOAP notes guide and the guide to mental health progress notes. You can also compare this case with the work stress example or the adolescent example.

Clara prepares an editable draft from the session. The clinician reviews what information is reported, what is observed and what falls to other professionals before adding it to the record. See AI clinical notes with Clara.