What is the recommended framework for describing autism symptoms in an office note?

From the Guidelines

The recommended framework for describing autism symptoms in an office note is the DSM-5 criteria, which organizes symptoms into two main domains: social communication/interaction deficits and restricted/repetitive behaviors. When documenting, clinicians should specifically note the presence and severity of symptoms in each domain, including difficulties with social-emotional reciprocity, nonverbal communication, developing relationships, repetitive movements or speech, insistence on sameness, fixated interests, and sensory sensitivities 1. The note should also include information about symptom onset, developmental history, functional impact across settings (home, school, community), and any comorbid conditions.

Some key points to consider when describing autism symptoms include:

• Persistent deficits in social communication and social interaction across multiple contexts
• Restricted, repetitive patterns of behavior, interests, or activities
• The presence of symptoms in the early developmental period, although they may not become apparent until social demands exceed the individual’s capacities 1
• Individual behavioral presentations are highly variable and largely driven by cognitive level, which can range from severely impaired to very superior ability 1
• Significant decreases in social function and quality of life are common, and even the most capable individuals often show problems navigating complex social interactions 1

Using standardized language from the DSM-5 framework also facilitates communication with other healthcare providers, educational professionals, and insurance companies, ultimately supporting better coordination of care for the patient. This structured approach ensures comprehensive documentation that aids in accurate diagnosis, treatment planning, and monitoring progress over time 1.

From the Research

Describing Autism Symptoms in Office Notes

When describing autism symptoms in an office note, it is essential to use a framework that accurately captures the complexity of the condition. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) provides a useful framework for identifying and describing autism spectrum disorder (ASD) symptoms 2, 3.

Key Symptoms to Document

Some key symptoms to document in an office note include:

• Social communication and interaction challenges
• Restricted and repetitive patterns of behavior, interests, or activities
• Severity of symptoms, which can be assessed using tools such as the Childhood Autism Rating Scale—2nd Edition Standard form (CARS2-ST) and the Clinical Global Impression (CGI)—Severity (CGI-S) and CGI—Improvement (CGI-I) scales 4

Treatment and Intervention

When documenting treatment and intervention, consider the following:

• Applied behavioral analysis (ABA), cognitive behavioral therapy, and speech therapy are preferred techniques for managing ASD symptoms 5
• Medications such as Risperidone and Aripiprazole may be used to address comorbid challenging behaviors, and their effectiveness can be monitored using the CARS2-ST and CGI scales 4
• Occupational therapy can also be a useful component of treatment, and may incorporate principles of ABA to support client-centered practice 6

Best Practices for Documentation

Best practices for documenting autism symptoms in an office note include:

• Using a standardized framework, such as the DSM-5 criteria, to ensure consistency and accuracy
• Documenting symptoms and severity in a clear and concise manner
• Regularly updating the office note to reflect changes in symptoms and treatment response 2, 3