How to document a first adult stimulant start

The first adult stimulant prescription is a controlled-substance start. The note has to show how you made (or confirmed) the diagnosis, baseline blood pressure and heart rate, a cardiac screen, PDMP review, diversion and misuse counseling, the drug, dose, days supply, and when you will see them again. “Start Adderall 20 mg for focus” is an order without that charting.

This is a first-start visit. Titration visits can be shorter; they should still carry BP/HR and a diversion line. Diagnosis work belongs in complex med-management only as an update, not as a second intake.

Show how you made the ADHD diagnosis

Adult ADHD is not a positive ASRS circle.

Document childhood onset (school records, parent/partner history, or a credible patient history of childhood symptoms), current DSM-5-TR criteria, impairment in more than one setting, and what you ruled out: bipolar, substance-induced inattention, sleep apnea, severe GAD, thyroid, uncorrected vision. If you used ASRS, CAARS, or DIVA, put the instrument name and the result in structured form, then interpret it. Screening is not diagnosis.

If the patient arrived with an old pediatric label and a 10-year gap, write how you re-established the diagnosis rather than copying the label forward.

Comorbid SUD does not automatically forbid a stimulant. It does require a sentence about risk, timing, and what formulation you chose (often a long-acting with closer follow-up).

Record baseline BP, HR, weight, and cardiac screen

Today’s BP, HR, and weight. Repeat if the first reading is high.

Cardiac: personal history of syncope, exertional chest pain, known arrhythmia or structural disease; family history of sudden death or cardiomyopathy. If anything is positive, write the ECG or cardiology step before you start, or why you started anyway.

“Vitals wnl, no cardiac history” is acceptable when you actually took vitals and asked. Do not let the EHR import last year’s BP from a dental visit.

Pregnancy status and current substance use (including cannabis, which many adults forget to mention) belong here. So does the rest of the med list: MAOIs are a hard stop; other agents may still change your choice.

Document PDMP, diversion risk, and counseling

PDMP queried, date, and a one-line result. If your state tool is down, write that and what you did instead.

Diversion and misuse: prior stimulant misuse, requests for immediate-release only, lost-script history, household members with SUD. Counseling: take as prescribed, do not share, safe storage, no alcohol binges on IR, call if chest pain or faintness.

Informed consent for a Schedule II: expected benefits (attention, impulsivity), common adverse effects (appetite, insomnia, HR/BP, anxiety), rare cardiac risk, and dependence/misuse. Patient’s questions and agreement.

If you used a treatment agreement, say it was signed. If you did not, do not pretend you did.

Write the start dose, days supply, and follow-up

Drug, formulation, dose, timing relative to meals and sleep, days supply (often 14 to 30 on a first fill, not 90), no early refills, pharmacy.

Avoid “as directed.” “Lisdexamfetamine 30 mg QAM, 14-day supply, zero refills” is a start.

Follow-up in 2 to 4 weeks for BP/HR, appetite, sleep, misuse, and whether work/school function actually moved. Tell them what would make you stop or switch: BP persistently over your clinic threshold, new chest pain, panic, or diversion concern.

If you chose atomoxetine, viloxazine, or bupropion instead, document why a stimulant is not first today. That is still a start note; it just starts something else.

Sample start note

Diagnosis: ADHD, combined, adult, DSM-5-TR met. Childhood: delayed
homework, two grade retentions per patient and older sister. ASRS
positive; not used as sole basis. Mimics: PHQ-9 6, GAD-7 7, TSH 1.8,
no mania history, UDS negative, PDMP 6/22/2026 no other controls.

BP 124/78, HR 76, wt 81 kg. No syncope, no family sudden death.
Counseling: storage, no sharing, appetite, insomnia, call for chest pain.
Start: lisdexamfetamine 30 mg QAM, #14, 0 refills. Follow-up 3 weeks
with BP log. Next visit: efficacy at work, sleep, appetite, repeat BP/HR.

Questions people ask

Do I need an ECG on every healthy 28-year-old? Not by default if history and vitals are unremarkable. If history is noisy, do not skip it to save the visit.

Can I start IR mixed amphetamine salts because “that’s what worked in college”? You can, but write why IR rather than a long-acting, and tighten days supply if diversion risk is not zero.