Dietitian Nutrition Care Process Note (ADIME)

Encounter type: [initial / follow-up]; [inpatient consult / outpatient MNT]; [in-person / telehealth]

Date/time: [Date and time of service]

Time spent: [Total minutes] (Only include if tracked)

Referral/consult context: [Consult order reason and ordering/referring provider; referral diagnosis or goal]

Patient context: [1–2 line clinical snapshot summarizing the patient and reason for nutrition involvement]

Interpreter: [Language and modality] (Only include if used)

Caregiver present: [Name/relationship] (Only include if present)

Assessment

(Use structured labeled lines for objective data. Attribute data sources throughout. Provide brief synthesis linking findings to nutrition problems.)

Food/Nutrition History

• Outpatient: [Typical eating pattern, dietary behaviors, prior nutrition education and response, readiness/barriers/supports] (Attribute source; use patient quotes sparingly for goals or barriers)
• Inpatient: [Current diet order with start date; actual intake vs ordered with % and timeframe; appetite and GI tolerance; data source]
• Nutrition support status: [None / Enteral / Parenteral; current vs planned; tolerance] (Only include if applicable)

Anthropometrics

• Height: [value] (Source: [measured / stated / chart])
• Current weight: [value, date] (Source: [measured in clinic / bed scale / stated / admit weight])
• Usual body weight: [value] (Source and timeframe) (Only include if known)
• Weight change: [amount and %] over [timeframe]; [intentional / unintentional]
• BMI: [value] (Include clinical interpretation only if it changes care)

Biochemical Data (Only include labs tied to nutrition decisions)

• Labs ([date]): [Relevant values with trends when known]
• Interpretation: [Brief link to nutrition care or precautions]

Nutrition-Focused Physical Findings

• [Document subcutaneous fat loss, muscle loss, edema/fluid status, skin/hair/nails, oral health/dentition, functional status as applicable with location and severity]
• NFPE not performed—[reason] (Only include if NFPE was not performed; do not leave blank)

Medical History, Allergies, Medications

• Nutrition-relevant conditions: [Diagnoses linked to nutrition care]
• Allergies/intolerances: [Substance and reaction type] (Only include if relevant to diet safety)
• Medications/supplements affecting nutrition: [Name and relevance] (Only include those materially affecting nutrition care)

Estimated Needs

• Energy: [kcal/day range] (Method: [equation or kcal/kg]; weight used: [actual / ideal / adjusted])
• Protein: [g/day range or g/kg] (Rationale: [clinical status])
• Fluid: [mL/day or mL/kg] (Only include if indicated)

Assessment Synthesis

[2–5 line narrative summarizing key drivers—intake adequacy, nutrition impact symptoms, weight trajectory, lab trends, functional findings—that lead into the nutrition diagnosis. State clinical reasoning influencing the prescription.]

Unavailable data: [What was attempted and why information could not be obtained] (Only include if key data is missing)

Diagnosis

(List 1–3 prioritized PES statements. For follow-ups, label each diagnosis status.)

• Diagnosis 1 [new / ongoing / improved / resolved]: [Problem] related to [Etiology] as evidenced by [Signs/Symptoms].
• Diagnosis 2 [new / ongoing / improved / resolved]: [Problem] related to [Etiology] as evidenced by [Signs/Symptoms]. (Only include if applicable)
• Diagnosis 3 [new / ongoing / improved / resolved]: [Problem] related to [Etiology] as evidenced by [Signs/Symptoms]. (Only include if applicable)

[No nutrition diagnosis at this time; monitoring plan: ...] (Only include if no current nutrition diagnosis)

Intervention

Nutrition Prescription

• Energy goal: [kcal/day range]
• Protein goal: [g/day range or g/kg]
• Fluid goal: [mL/day] (Only include if indicated)
• Diet: [Texture/consistency and therapeutic restrictions as indicated]
• Condition-specific parameters: [e.g., sodium, potassium, CHO targets] (Only include if clinically necessary)
• Diet order and modifications: [Current order and recommended changes with rationale] (Only include for inpatient)

Interventions by Diagnosis

• For Diagnosis 1:
  • [Interventions performed this encounter]
  • [Orders/recommendations placed or pending]
  • [Patient-centered goals in patient's words]
  • [Care team coordination and communication]
• For Diagnosis 2: (Only include if applicable)
  • [Interventions, orders, goals, coordination]

Education and Counseling (Only include if provided)

• Learner: [patient / caregiver / both]
• Topics and takeaways: [Content linked to goals]
• Readiness/barriers: [Motivation, confidence, access, literacy, cultural factors discussed]
• Understanding assessed via: [teach-back / return demonstration / Q&A]; [patient response]
• Materials provided: [Handouts, resources, format]
• Reinforcement plan: [How/when to revisit]

Safety and Escalations (Only include if relevant)

• [Refeeding risk precautions and actions]
• [Dysphagia concerns and SLP involvement]
• [Provider notifications: what, to whom, when]

Monitoring and Evaluation

(Tie indicators to each diagnosis with measurable targets and timeframes.)

• For Diagnosis 1: [Intake target, weight trend goal and frequency, GI tolerance, labs and timing, patient-reported outcomes]
• For Diagnosis 2: [Monitoring indicators and targets] (Only include if applicable)

Follow-up Plan

• Inpatient: [Reassessment interval] and [triggers for earlier follow-up] (Only include for inpatient)
• Outpatient: [Follow-up timeframe], [labs to obtain before next visit], [data patient should track/bring] (Only include for outpatient)

Malnutrition Documentation

(Only include if malnutrition is present or being assessed.)

• Context: [acute illness/injury / chronic illness / social-environmental circumstances]
• Diagnostic characteristics present: [Energy intake reduction, weight loss %, body fat loss, muscle loss, fluid accumulation, reduced grip strength—include location, severity, timeframe, and source for each]
• Severity: [moderate / severe] malnutrition per [institutional protocol/criteria]
• Link to plan: [How malnutrition status informs interventions and monitoring]

Enteral Nutrition

(Only include if applicable.)

• Access: [Device type and location]
• Formula: [Name, kcal/mL]
• Regimen: [Rate/schedule: continuous / cyclic / bolus]; [Flushes: water volume and frequency]
• Estimated provision: [kcal, protein, fluid per day]
• Tolerance: [Residuals, GI symptoms, metabolic labs]
• Advancement plan: [Steps and precautions]
• Discharge planning: [Supplies, education, home arrangements] (Only include if relevant)

Parenteral Nutrition

(Only include if applicable.)

• Access: [PICC / central line / port]
• Macro prescription: [Dextrose g/day; amino acids g/day; lipids g/day]
• Micronutrients/electrolytes: [Additives and targets]
• Infusion schedule: [Continuous / cyclic]; [total volume]; [duration]
• Monitoring: [Labs and frequency]
• Adjustments/precautions: [As relevant]

Billing Documentation

(Only include for outpatient MNT when payer documentation is required.)

• MNT indication: [ICD-10 diagnosis]
• Referral verified: [yes / no]; [date]; [referring clinician]
• Time: [Total minutes or units]

Closing

[Brief concluding statement summarizing plan and next steps]

Signature: [Name], [Credentials], [Role/Department]