In Part 1 I went through what an adult ADHD evaluation actually has to establish, and why each piece of it is harder than it looks written down. This is the other half of the problem. Knowing what a good evaluation requires is not the same as being able to run one thirty times a year in a solo practice without it eating your schedule alive. If you have not read Part 1, start there.
So the question here is narrower and more practical. How do you turn that standard into a process that is thorough enough to hold up, without putting every patient through three visits, six questionnaires, a two-hundred-dollar computerized test, and a neuropsych referral?
I want to start with the trap, because it is the one I see most often and it is the reason this post is not called "how to survive an audit."
The most defensible-looking process is often the least defensible
A member here once laid out a workflow they were considering. Anyone reporting ADHD symptoms at the initial visit does a paid screening tool. They come back to review the results. If the screener suggests ADHD, they take a second paid computerized test. Then a third visit before anything gets prescribed. The stated reasoning was that this would build a defensible case if they were ever audited, and would filter out people just looking for a quick prescription.
I understand the instinct completely. More documents feels like more protection. But look at what that workflow actually produces. The patient is sent through a series of tests, and then the clinician reviews the printouts. What is missing is the clinician's own evaluation and judgment, which is the most defensible and meaningful part of the entire process. You have built a paper trail around the thing you removed.
This matters beyond the philosophy of it. That workflow costs the patient several hundred dollars and three appointments before anyone has decided anything, which is its own access problem. It front-loads the parts you can buy and defers the part only you can do. And in an actual audit, a stack of vendor-generated reports without a documented line of clinical reasoning is weaker, not stronger, than a single well-reasoned note.
The principle I would build everything else on: a process becomes defensible because it demonstrates sound clinical reasoning, not because it accumulated enough instruments. Design for the reasoning, and defensibility comes along as a byproduct. Design for the imaginary auditor, and you get questionnaire-stacking that protects nobody.
Before they book
The cheapest place to solve a fit problem is before it becomes an appointment.
In my practice the first contact is a phone screen. My assistant asks what medications they are currently on, confirms basic demographics and insurance, and does a quick fit check. If you do not have an assistant, this is a five-minute call or email you do yourself, and it is still worth the five minutes.
The part worth stealing is putting your actual policies in writing, in front of people, before they commit. Two examples from my own practice.
I run a blanket no-benzodiazepine policy, and it is deliberate. I tried a more relaxed version first, because I will occasionally prescribe a benzodiazepine as a rare PRN, but the relaxed version did not catch people. I would get a lot of "I only use it infrequently," and then find out either that they did not, or that their definition of infrequent was miles from mine. The blanket policy is simply cleaner. I say I do not prescribe them. If I identify an established patient who genuinely needs a PRN, I prescribe it. I just do not advertise that.
Cannabis is harder to screen for on a phone call, because an assistant is not trained to tease that out, so I handle it as a stated boundary rather than a screen. Two ways to word it, depending on how much room you want to leave:
Softer, invites the willing: If you use cannabis regularly, that becomes part of our work together, since chronic daily use can worsen anxiety, depression, ADHD symptoms, and sleep. I also generally do not prescribe stimulants alongside regular cannabis use.
Firmer, draws the line: I do not prescribe stimulants to patients using cannabis regularly or daily. If that is a dealbreaker, I would rather be upfront about it now than after we have started.
Either way, having it in writing before they book does the screening for you, and it self-selects out the people who are not open to the conversation without you having to be the bad guy in the first appointment. Note that this is a practice-boundary decision, not a diagnostic one. The diagnostic reasoning about cannabis is in Part 1, and the two should not be confused with each other.
What you send ahead, and why
The intake packet does the work that does not need you in the room. Consents, telehealth consent, the Good Faith Estimate, HIPAA notice, card on file, insurance upload, and a comprehensive history covering social, medical, psychiatric, and substance use.
For an ADHD question specifically I usually add an ADHD rating scale, often the ASRS, and may add a functional measure such as the WFIRS. I want to be precise about what I am getting from them. They standardize one small piece of the assessment, surface symptom and impairment areas worth exploring in the interview, and give me a baseline data point I can put alongside the rest of the history. What they do not give me is the context, chronology, developmental pattern, compensation, or meaning behind the endorsement. That still comes from the interview.
One or two targeted measures can be useful. Five measures usually give you more paperwork, not five times the diagnostic information.
What I do not do is treat the returned packet as a completed history. It is a starting point that makes the appointment better, not a substitute for the interview.
Collateral, without chasing people for a month
Part 1 argued that collateral is one of the few inputs that can add genuinely new signal, because it gives you a perspective a solo interview structurally cannot produce. That is easy to say and genuinely annoying to operationalize, so here is how I keep it from becoming an open-ended errand.
I usually think about collateral in two buckets. Who can tell me what this person was like developmentally, and who can tell me what functioning looks like now? Sometimes that is the same person. Often it is not. A spouse who met the patient at thirty-five may be excellent current collateral and completely useless for childhood onset. A parent may remember school vividly and know almost nothing about how the patient functions at work now. Knowing which bucket you are trying to fill changes who you ask and what you ask them.
Ask at the first appointment, not after. By the time you have decided you want collateral, the patient has usually left, and a request that arrives by portal message a week later gets ignored. Ask in the room, name the bucket, and let the patient choose the person. For developmental history the question is not "can I talk to your mother," it is "who knew you at eight and would remember what school was actually like."
Make it small. A structured questionnaire the informant can complete in fifteen minutes gets returned far more often than an open request for a phone call. If a call is what you need, offer two specific windows rather than asking them to coordinate with you.
Set a deadline out loud, and say what happens if it passes. Something like: if I have not heard from your sister in two weeks, we will look at what we have and decide whether there is enough to reach a conclusion, or whether that missing history matters enough to wait. That sentence does two things. It stops the evaluation from stalling indefinitely, and it tells the patient the information matters, which noticeably improves the return rate.
And when collateral genuinely does not exist, which happens often with estranged families, deceased parents, or immigration histories, say so in the chart and weigh the rest accordingly. Absent collateral is not a reason to refuse to think. It is a reason to hold the conclusion a little more loosely and to write down that you did.
The appointment, and what it actually costs you
The UK adult ADHD assessment standard suggests two hours or more for an adequate assessment including the post-assessment discussion, potentially split across sessions. I think that number is worth sitting with rather than dismissing, because it is the honest price of the thing Part 1 described. It is also worth being clear about what it is: a UK quality standard, not a United States legal or billing requirement. There is no magic minimum duration that makes an ADHD evaluation legitimate.
In a real private practice, two uninterrupted hours for one intake is not always available. If the work genuinely does not fit in one visit, split it deliberately rather than forcing it. A long initial evaluation, then a scheduled follow-up where the collateral and any outstanding history get integrated and the actual diagnostic conversation happens. That is not the same as the three-visit gate I criticised above, and the difference matters. In that model the visits exist to run tests. In this one they exist because the clinical work genuinely does not fit in one sitting, and the second visit is where the reasoning gets done rather than where a printout gets reviewed.
Prep is what makes this survivable. I block time before the week starts to transfer intake details into the chart, so that the appointment is spent on history, formulation and plan rather than on data entry. I have written about that general prescriber workflow before and it applies here with more force than usual, because the ADHD evaluation is exactly the appointment where you cannot afford to spend twenty minutes typing.
Three honest outcomes
An evaluation appointment has three legitimate endings, and naming them in advance makes each one easier to deliver.
You diagnose. The developmental pattern, cross-setting impairment and functional cost line up, the differential has been worked, and you document the reasoning rather than the score.
You defer. Something material is still unresolved: developmental collateral you actually need has not arrived, untreated sleep apnea is significantly clouding the picture, daily cannabis use has made the chronology impossible to sort out, or an active mood episode makes the current symptom picture unreliable. Note that it is the effect on the reasoning that matters, not the mere presence of the thing. Deferring is a clinical decision, not a failure, and it should be framed as a sequence rather than a refusal. Treat what is clearly present, then look at what is left. Say when you will revisit it.
You reformulate. The presentation is better explained by something else, and the honest answer is that this is not ADHD. Part 1 has the language I use for this conversation, including the referral criteria, which are about a differential that has outgrown the setting rather than about ADHD being difficult.
Whichever ending you reach, it belongs in the note as a conclusion with reasoning attached, not as a code with a score underneath it.