An ADIME note records nutrition care in four parts: Assessment, Diagnosis, Intervention, and Monitoring and Evaluation. Copy the free template, see an outpatient diabetes example and an inpatient weight-loss example, and learn to write PES statements.
Blank ADIME note template
FreeADIME NOTE Patient: [Name] Date of birth: [Date] Date of visit: [Date] Visit: [Initial or follow-up; in person, phone, or video] Referred by: [Name, and reason for referral] Dietitian: [Name, credentials] ASSESSMENT Food and nutrition history: [Usual intake or 24-hour recall, meal pattern, beverages, supplements, food access] Anthropometrics: [Height, weight, BMI, usual weight, and weight change over time] Biochemical data and tests: [Relevant labs with dates and units, and medical tests] Nutrition-focused physical findings: [Muscle and fat loss, edema, oral health, swallowing, appetite, GI symptoms] Client history: [Diagnoses, medications that affect nutrition, living situation, activity] Estimated needs: [Energy, protein, and fluid, with the method or equation used] DIAGNOSIS PES statement 1: [Problem related to etiology as evidenced by signs and symptoms] PES statement 2: [Problem related to etiology as evidenced by signs and symptoms] INTERVENTION Nutrition prescription: [Energy, protein, fluid, and any nutrient, texture, or meal pattern targets] Food and nutrient delivery: [Diet order, meals and snacks, supplements] Education: [Topics covered, materials given, understanding shown] Counseling: [Approach used, and the goals the patient chose] Coordination of care: [Referrals, and who was updated on the plan] MONITORING AND EVALUATION Indicators: [What will be tracked, linked to each PES sign or symptom] Criteria: [Target for each indicator, with a time frame] Follow-up: [When, how, and with whom] Signed: [Dietitian name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient clinic, initial visit, referred by family physician
54-year-old man with type 2 diabetes for 2 years, referred for diabetes nutrition care. 24-hour recall: skips breakfast; coffee with 2 sugars; fast-food lunch with fries; 2 cans of regular soda a day, about 80 g of sugar; large pasta dinner at 21:00. Eats in the car on workdays. Two beers on weekends. Height 175 cm (69 in), weight 98 kg (216 lb), BMI 32; up 4 kg (9 lb) in the last year; waist 108 cm (42.5 in). Labs last month: A1C 8.4%; fasting glucose 9.1 mmol/L (164 mg/dL); LDL cholesterol 2.9 mmol/L (112 mg/dL); eGFR 82. No muscle or fat loss; no GI symptoms. Takes metformin 1,000 mg twice daily with meals. Walks 10 minutes most days. Estimated needs: about 1,850 kcal a day for gradual weight loss (Mifflin-St Jeor, activity factor 1.3, minus 500 kcal); protein 80 to 100 g a day; fluid 2 to 2.5 L a day.
Excessive carbohydrate intake related to sugar-sweetened drinks and large evening meals, as evidenced by about 80 g of sugar a day from soda in the 24-hour recall and an A1C of 8.4%. Food- and nutrition-related knowledge deficit related to no previous diabetes nutrition education, as evidenced by skipping breakfast to “keep his sugars down” and not knowing which foods contain carbohydrate.
Nutrition prescription: about 1,850 kcal a day; carbohydrate spread across 3 meals using the plate method; no sugar-sweetened drinks; protein 80 to 100 g a day. Education: carbohydrate foods, the plate method, reading labels for sugar, and why skipping meals doesn’t help glucose control; handouts given; sorted 10 foods into carbohydrate and non-carbohydrate groups correctly. Counseling: motivational interviewing; he chose 2 goals: water or sparkling water instead of soda on workdays, and a breakfast with protein 5 days a week. Coordination: summary sent to his family physician; group diabetes education class booked.
Indicators: soda intake, breakfast days a week, weight, and A1C. Criteria: soda no more than 1 can a week and breakfast 5 days a week by the next visit; weight down 2 to 4 kg (4 to 9 lb) in 3 months; A1C rechecked by his physician in 3 months, toward the target his care team sets. Follow-up: video visit in 4 weeks, with a 3-day food record kept beforehand.
Medical ward, inpatient consult, day 2 of admission
82-year-old woman admitted 2 days ago after a fall at home, with no fracture; referred by nursing after a positive malnutrition screen. Eating about half her usual meals for 3 months; finds shopping and cooking hard since an earlier fall; avoids meat and raw vegetables because her lower denture is loose. In hospital, eating 25 to 50% of meals. Height 160 cm (63 in); weight 52 kg (115 lb), BMI 20; usual weight 58 kg (128 lb) 3 months ago, a 10% loss. Sodium, potassium, phosphate, and magnesium normal; albumin 31 g/L (3.1 g/dL), noted but not used to diagnose malnutrition. Moderate muscle loss at the temples, collarbones, and shoulders; mild fat loss around the eyes; no edema; grip strength reduced. Lives alone; her daughter visits weekly. Estimated needs: 1,560 to 1,820 kcal a day, 30 to 35 kcal/kg; protein 62 to 78 g a day, 1.2 to 1.5 g/kg; fluid about 1.5 L a day. Refeeding risk: weight loss over 7.5% in 3 months.
Severe malnutrition in the context of social or environmental circumstances, related to difficulty shopping and cooking and a loose denture, as evidenced by a 10% weight loss in 3 months, intake about 50% of needs for 3 months, and moderate muscle loss. Biting and chewing difficulty related to a poorly fitting lower denture, as evidenced by avoiding meat and raw vegetables, and a denture that moves when she chews.
Nutrition prescription: 1,560 to 1,820 kcal and 62 to 78 g protein a day; fluid about 1.5 L a day. Food and nutrient delivery: soft, moist diet with sauces for easier chewing; high-energy, high-protein oral nutrition supplement twice a day between meals; snacks at 15:00 and 20:00; help opening packages at meals. Education: why small, frequent meals and supplements help; her daughter included by phone. Coordination: refeeding risk flagged to the team, with phosphate, potassium, and magnesium requested daily for 3 days, and thiamine for the team to consider; weekly weights; occupational therapy and social work asked to assess meal preparation and shopping support before discharge; dental review for the denture added to the discharge plan.
Indicators: percent of meals and supplements taken, weight, electrolytes, and chewing comfort. Criteria: intake at least 75% of estimated needs within 1 week; weight stable or rising by discharge; phosphate, potassium, and magnesium within range. Follow-up: reassess on the unit in 3 days; outpatient dietitian follow-up after discharge.
The data you gathered, grouped by the nutrition care process domains, ending with estimated needs.
Avoid: A BMI with no weight history. A 10% loss in 3 months matters even when the BMI looks normal.
The nutrition problem you can treat, written as a PES statement: Problem, related to Etiology, as evidenced by Signs and symptoms.
Avoid: Using a medical diagnosis as the problem. Type 2 diabetes is the reason for referral; excessive carbohydrate intake is a nutrition diagnosis.
What you did and recommended, aimed at the etiology of each PES statement.
Avoid: An intervention that misses the cause. If a loose denture is the problem, a supplement alone won’t fix it.
How you, and the next clinician, will know whether it worked.
Avoid: “Will monitor” with no target or date.
“Related to type 2 diabetes” gives you nothing to change. The etiology should be a cause you can address, such as sugary drinks or limited nutrition knowledge.
“As evidenced by poor intake” can’t be tracked. Use the data: intake about 50% of needs for 3 months, or a 6 kg (13 lb) loss.
Albumin and prealbumin reflect inflammation and fluid status more than nutrition. Base the diagnosis on intake, weight change, muscle and fat loss, fluid accumulation, and grip strength.
Each indicator should match a sign or symptom in a PES statement, so the follow-up note can say resolved, improving, or unchanged.
For patients with major weight loss or very low intake, note the risk and the electrolytes to check before intake rises.
Vero Scribe writes the ADIME note in your template from the session conversation, with the patient’s consent, or from your dictation. You review the PES statements, edit, and copy the note into your EMR.
Assessment, Diagnosis, Intervention, and Monitoring and Evaluation. It follows the steps of the nutrition care process, so the note mirrors how dietitians work.
Name the Problem, its Etiology, and the Signs and symptoms that show it: problem, related to cause, as evidenced by data. For example: “excessive carbohydrate intake related to sugary drinks, as evidenced by about 80 g of sugar a day from soda.”
ADIME follows the nutrition care process and gives the nutrition diagnosis its own section, as a PES statement. SOAP separates what the patient reports from what you measure. Both work; use what your organization asks for.
Usually one or two, highest priority first. If several problems share a cause, address the cause in one statement.
Yes. Copy it, or download it as a Word or text file. No account needed.
ADIME and SOAP nutrition note examples, and nutrition follow-up.
Shared templates and handoffs for nutrition practices.
Seven worked notes in different formats, with review checks.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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