Published October 2025

Best Practices for ADHD Documentation

October marks ADHD Awareness Month, dedicated to raising understanding and reducing stigma. ADHD affects about 6 million children in the U.S., often continuing into adulthood and impacting daily life. It is frequently underdiagnosed or misunderstood. Clear documentation supports timely diagnosis, effective treatment, and access to care.

When documenting ADHD, providers should capture:

• Onset & Duration: Note when symptoms began and how long they've persisted
• Multi-Setting Impact: Describe challenges across settings (home, school, work)
• Behavioral Examples: Include specific, observable behaviors
• Assessment Tools: Document scores and who completed tools (e.g., Vanderbilt, Conners)
• Differential Diagnoses & Comorbidities: Mention other possible or coexisting mental health or learning conditions
• Treatment Plan: Outline medications, behavioral strategies, and goals
• Symptom Response: Track improvements and side effects over time
• Severity & Remission: Indicate level (mild/moderate/severe) and remission status if applicable

ADHD Code Set:

*Please refer to the ICD-10-CM coding manual for an all-inclusive list of codes