The GP Letter (ADHD) template by s10.ai is expertly crafted for psychiatrists to meticulously document comprehensive assessments of patients with suspected ADHD. Featuring sections for patient history, DSM V criteria, mental health examination, and risk assessment, this template is perfect for generating structured and detailed reports for general practitioners. It ensures that all pertinent clinical information is communicated effectively. Utilizing this template with s10.ai allows clinicians to streamline the documentation process, guaranteeing accuracy and thoroughness in ADHD evaluations. This tool is especially beneficial for capturing the complexities of ADHD symptoms and their effects on daily life, motivating clinicians to adopt and implement this efficient solution.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
I am writing to you regarding my patient, John Doe, who visited my clinic on October 15, 2023.John arrived at the clinic expressing concerns about ongoing inattention and difficulty maintaining focus at work, persisting for the past six months. He notes that these symptoms have considerably affected his job performance and social interactions.According to the DSM V criteria for ADHD, John displays symptoms of inattention, daydreaming, and procrastination. He recalls experiencing similar issues during his childhood, including classroom disruptions and academic challenges. Based on these observations, John meets the criteria for DSMV diagnostic codes for ADHD.John has a history of anxiety, diagnosed in 2018, for which he underwent cognitive behavioral therapy with moderate success. There is no history of self-harm or harm to others, and he has never required hospital admission.John reports occasional alcohol use, with no history of problematic use or addiction. His last use was a week ago.There is no criminal history to report.Family history indicates that John's father had depression, and his mother has hypertension.John's medical history includes a tonsillectomy at age 10, and he reports no cardiac history.Currently, John is supported by a psychologist and has a strong support network of friends and family.John grew up in a stable family environment, with no reported childhood trauma. He has a close attachment to his parents and has achieved a bachelor's degree in engineering. He has maintained stable employment in his field.The mental health examination shows John is alert and oriented, with a cooperative demeanor. His mood is anxious, and his affect is congruent. Thought processes are logical, and there are no delusions or hallucinations.John's height is 180 cm, weight is 75 kg, blood pressure is 120/80 mmHg, and BMI is 23.1.Impression: John presents with symptoms consistent with ADHD, primarily inattentive type.Risk assessment: Low risk of harm to self or others.Plan: Initiate a trial of stimulant medication, continue with cognitive behavioral therapy, and schedule a follow-up appointment in four weeks.
Key advantages of using this template in clinical practice
Common questions about this template and its usage