Attention Deficit / Hyperactivity Documentation

Attention Deficit/ Hyperactivity Disorder (AD/HD) is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development. The manifestations of AD/HD result in functional impairment in at least two settings (e.g., academic, occupational, social). The diagnosis of AD/HD is based on the following specific criteria included in the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association.

Documentation guidelines for AD/HD include: 

General documentation guidelines 

• Diagnosis and corresponding code from the most recent DSM must be included.
• Assessment of the following diagnostic criteria is required and evaluation results must be included in the documentation:
  • Developmental history of either inattention and/or hyperactivity-impulsivity symptoms during childhood. The specific symptoms that were present in childhood should be stated in the documentation. Corroboration of childhood symptoms should be included, and may need to be gathered from a variety of possible data sources (e.g., parent/guardian report, school records, past evaluations). Evidence that these symptoms were associated with some functional impairment in home and/or school settings also must be included.
    
    
  • Current symptoms of either inattention and/or hyperactivity-impulsivity must be present. The specific symptoms that are present should be stated in the documentation. Self-reported current symptoms should be corroborated by an independent informant who has been able to observe the student's recent functioning with adequate regularity to provide this type of information. Evidence that these symptoms are associated with functional impairment in academic, occupational, and/or social settings also must be included.
    
    
  • The frequency/severity of both childhood and current AD/HD symptoms should be documented by comparison to individuals at a similar level of development. Documentation must include the results of standardized rating scales that provide comparison to age-based normative data.

AD/HD Criteria for Health Professional

Think you have a disability, but never been evaluated? Contact a qualified licensed provider in your insurance’s network or email tds@augusta.edu for referral information.

*TDS does not test or evaluate students for disabilities in our office but we can help you with referrals and steps to get tested.*

Learn more about documentation requirements on the Documentation Criteria 101 page.