How do you manage ADHD in your clinic?

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Can NPs diagnose ADHD? I live in Texas, and I'm struggling to find scope of practice information specific to ADHD on BON website. I'm curious to know how other practices manage diagnosing and prescribing meds, particularly in states where NPs are not permitted to prescribe schedule II meds.

At my clinic, the makes the diagnosis and initiates treatment. Follow-ups may be done with NP, who may make recommendations to the physician, but the prescription still must be written by the physician. Recently, my physician has said "I trust you", regarding making the diagnosis. I certainly don't want to violate scope of practice. I'm an FNP.

Specializes in Cardiology, Research, Family Practice.

*in response to canigraduate

I am an FNP and I work in family practice and I treat children and adults and I'm familiar with the guidelines.

I don't mind giving that info, but as I stated, I'm interested to hear how other practices manage the process of diagnosing and treating, e.g. does the clinic permit the NP to diagnose ADHD, or does the clinic require that only the physician make this diagnosis. It's just helpful to hear how other practices manage the day to day process. This forum can be a great place to share tips, "this is what works for me", etc.

Regarding referring out ADHD, this is simply not practical as there is a shortage of psychiatric practices/specialty practices across the country. Not to mention that those available often have very long waits (months) and/or do not accept insurance.

Finally, as an FNP, I do consider myself a mental health provider.

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Specializes in Psychiatric Nursing.

@Good NP. You might want to call your BON or your malpractice carrier. Also review your certification-if there are any restrictions or guidelines about FNP doing mental health. There are different certifications for FNP and PMHNP and there is an overlap.

Every state I worked I am responsible to make diagnosis within my scope of practice as a psych aprn.

I cannot fathom how you can run a busy FNP clinic and have time to evaluate and treat psychiatric issues.

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Specializes in Outpatient Psychiatry.

If you're covered to treat ADHD then have at it. There is no reason it needs to be a physician only doagnosis. The only hang up is that Schedule II inconvenience.

As I said, the only art to it is in exercising the medication. A lot of NPs and any PCPs really perceive that giving More of an XR capsule will make it last longer. Putting aside the graphs and cool drug company junk, that typically doesn't have the intended effect. Often that presents an adverse effect.

And always cover your bum, prove you've been trained to do it. If anything, just do an online CME.

If you want I'll send you my entire ADHD population, lol.

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Specializes in Outpatient Psychiatry.
@Good NP. You might want to call your BON or your malpractice carrier. Also review your certification-if there are any restrictions or guidelines about FNP doing mental health. There are different certifications for FNP and PMHNP and there is an overlap.

Every state I worked I am responsible to make diagnosis within my scope of practice as a psych aprn.

I cannot fathom how you can run a busy FNP clinic and have time to evaluate and treat psychiatric issues.

My evals are scheduled for 15 minutes. And she's not doing any kind of psychotherapy which I don't do either so I think she's OK. It's really a matter of knowing when to ask what questions.

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Specializes in Psychiatric Nursing.

15 minutes! New evals! How do you do it? And what code do you use? Does this include documentation? Any efficiency tips to share?

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Specializes in Outpatient Psychiatry.
15 minutes! New evals! How do you do it? And what code do you use? Does this include documentation? Any efficiency tips to share?

Well, the patients all get to the therapist first and they do their initial spill which I skim over. Incidentally, the patient's treatment goals populate a box above my HPI box so it makes for quick reflection. Seldomly does one come to me without documentation. Those visits might take 20 minutes. I did evaluate a woman for an hour earlier this week. For as long as she's been in service with us, she'd never had a detailed assessment by anyone. I get all of the social history off the therapist's chart so to corroborate I'll ask how old, job, what grade, who they live with it. Family history I'll type like "maternal - bipolarity, anxiety" or whatever, instead of mom's great aunt, mom's sister, etc. Seldomly do I get into the specifics of each relationships. Unless I'm treating expressly for addiction, I write something like "smokes 1 PPD cigs, 4-5 beers on the weekend, denies illicit drug use." I like "illicit." It sets my documentation apart from anyone else, lol.

Medical history, I ask, "any head injuries, thyroid, diabetes, liver, kidney, heart, headache or seizure problems." If they have a chronic illness like SLE or fibro they're usually quick to share. And the chronic pain people want you to know about their pain so a lot of them run off at the mouth about that like I'm going to write Percocet for them. You know the drill.

I then tailor the lion's share of my questions to a chief complaint and ancillary symptoms, make a timeline out of it, and go from there. The HPI is of course the most of my writing. I use the MSE to cover a lot. If say on the rare occasions some type of mood disorder person doesn't reveal psychosis, and I'm ticking down my MSE checkoffs and hit hallucinations and they answer "yes" I'll go back to the HPI.

I bill only 3 codes: 90792 "psychiatric diagnostic evaluation with medical services" as well as 99213 and 99214. Each of those three have a template designed specifically to meet the documentation and billing requirements of each code along with adequate space for extra narration.

I type everything while the patient talks and don't let them leave until I'm done and have submitted the chart. That prevents me from being over run by my nurse wanting to bring the next one in. I do admire her efforts to move quickly.

I also type like a machine gun. It slows as the day goes by, and by 4:30 many of my appointments do run over. I also double book many of my appointment slots knowing that many won't show up. By the end of the day, it all evens out.

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Specializes in Psychiatric Nursing.

@psych guy. Thanks for your descriptions. I have an outpatient Locums job coming up and was trying to imagine 15 mi. Evals.

Back to the OP. Another place to look for guidelines re:your scope of practice is the "community standard". How do clinics in your geographical area handle adhd. Also if you have written guidelines with your collaborator you could incorporate diagnosing.

I try not prescribe stimulants and try other things first.

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At my shop, if it's an adult that doesn't do anything then they get nothing but Strattera or Wellbutrin.

PsychGuy, can you please explain what you mean by this comment? Thanks, Julia

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Specializes in Outpatient Psychiatry.
At my shop, if it's an adult that doesn't do anything then they get nothing but Strattera or Wellbutrin.

PsychGuy, can you please explain what you mean by this comment? Thanks, Julia

They don't get the much coveted Adderall.

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Specializes in Cardiology, Research, Family Practice.
They don't get the much coveted Adderall.

I wondered what you meant by "an adult that doesn't do anything". I presumed you meant an adult who doesn't work, go to school, stay at home parent, etc.

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Specializes in Outpatient Psychiatry.
I wondered what you meant by "an adult that doesn't do anything". I presumed you meant an adult who doesn't work, go to school, stay at home parent, etc.

Oh, yep. Sorry. That's precisely what I meant. It's "those" that of course most frequently want stimulants.

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Children do not just "outgrow" ADHD and up to 50-60 percent will still have symptoms in adulthood especially in attention.

It is important to make an accurate diagnoses and being sure to rule out any DDs such as learning disabilities which can be co-morbid and complicate treatment if not addressed.

For assessment I require some teacher input sometimes I just take observations from documentation from a 504 that is in place at school or have a teacher fax me a copy of the Vanderbilt.

I would highly recommend referring these cases to make sure that it may not be something else or another mental health condition going on as well. Plus mental health can help parents and

children with coping skills in addiction to medication.

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