Chronology of the Management of a Child Who Has ADHD
This chronology outlines the components of the medical record that document the management of a child named Walter Major, date of birth April 17, 1985, who is in second grade. The actual content and wording in the medical record will differ from this listing, which is presented solely to demonstrate the use of the summary sheet (Figure).
March 3, 1993
Initial conference with parents. School raised issue of attentional disorder. Discussion of ADD/LD. Relevent history in record reviewed and amplified by questioning. Further information requested from school.
March 23
Note from teacher received describing Walter's behavior. Report cards included from this year, first grade, and kindergarten. Behavior scales sent to teacher and parents.
March 31
Scales returned by parents and teachers. Observations consistent and strongly indicative of attentional disorder with element of hyperactivity.
April 7
Complete physical examination, including neurologic evaluation. Height, 50 in; weight, 55 lb; blood pressure, 105/60 mmHg. Results of scales and examination discussed with parents.
April 8
Telephone conversation with teacher. She strongly suspects ADHD but does not feel he has LD. Strategies discussed for environmental controls at school.
June 16
Conference with parents. Walter has done better but not as well as hoped for. Parents want "learning testing" and prefer to have it done privately over the summer.
