Initial Nutrition Assessment Note (ADIME)

Patient: [Full name and second identifier per facility policy]
Date/Time: [Encounter date] at [Start time]
Location: [Inpatient / Outpatient / Clinic name]
Visit Type: Initial Nutrition Assessment
Referring Provider: [Provider name]; Consult Reason: [Reason for referral]
Dietitian: [Name, credentials]

Assessment

Reason for Consult and Patient Goals
[Chief nutrition concern and precipitating factors] (Describe what prompted the visit now, such as new diagnosis, symptoms, weight change, or lab findings. Include patient-stated goal in the patient's own words when it clarifies motivation or barriers.)

Data Sources
[Patient interview / Caregiver report / Interpreter-assisted interview / EHR review / Food logs / Lab results / Other] (List sources in one line. Include reliability qualifiers when relevant, e.g., "limited recall," "3-day food log reviewed.")

Food and Nutrition-Related History
Current intake pattern and context: [Typical meals/snacks structure and timing; eating environment; who shops/cooks; hydration and key beverages including alcohol if relevant]
24-hour recall or usual intake summary:

• [Time]: [Foods/beverages and estimated portions]
• [Time]: [Foods/beverages and estimated portions]
• (Use time-based list if available; otherwise provide a concise usual intake summary.)

Cultural/religious or texture-modified dietary practices: [Specify] (Include only if relevant.)
Symptoms affecting intake: [Appetite changes / GI symptoms / Chewing or swallowing issues / Taste changes / Nausea / Vomiting / Diarrhea / Constipation / Early satiety / Other] (Include frequency, severity, and relationship to intake.)
Food allergies and intolerances: [Allergen or intolerance, reaction type, severity] (Differentiate allergy vs intolerance.)
Nutrition knowledge, readiness, and learning style: [Current knowledge level, readiness to change, preferred learning style]
Food access and social context: [Access to food, financial constraints, living situation, support system, transportation, relevant SDOH factors]

Anthropometrics and Weight History

• Height: [Value with units] [measured / patient-reported] — [date]
• Weight: [Value with units] [measured / patient-reported] — [date]
• BMI: [Value] kg/m²
• Usual Body Weight (UBW): [Value with units] — [timeframe/source]
• Weight change: [Amount and % change] over [timeframe]; [intentional / unintentional]; contributing factors: [Brief description]
• Other measures: [Waist circumference, mid-arm circumference, handgrip strength, etc.] (Include only if available.)

Interpretation: [Brief synthesis of weight trend and clinical relevance] (Note caveats such as edema, fluid shifts, or scale differences.)

Biochemical Data

• Glycemia: [Glucose, A1c, CGM summary — values and dates]
• Renal/Hepatic: [BUN, Cr, eGFR, AST/ALT, albumin/prealbumin — values and dates]
• Lipids: [TC, LDL-C, HDL-C, TG — values and dates]
• Micronutrients: [Iron studies, B12, folate, vitamin D, etc. — values and dates] (Include only if relevant to referral.)
• Other pertinent: [Electrolytes, CRP, TSH, etc. — values and dates]

(If no recent labs: "No recent labs available; requested/awaiting: [specify].")

Medications and Supplements

• Medications with nutrition impact: [Name, dose/frequency; note effects on appetite, glycemia, GI motility, weight, or nutrient interactions]
• Supplements/vitamins/herbals: [Product, dose, frequency]

Nutrition-Focused Physical Exam (Include only when malnutrition risk, significant weight change, or micronutrient concern is present.)

• Status: [Performed / Partially performed / Deferred] (If deferred, state reason: telehealth, time constraints, patient declined.)
• Subcutaneous fat: [Findings and locations assessed]
• Muscle mass: [Findings and locations assessed]
• Fluid accumulation: [Edema/ascites — distribution and severity]
• Micronutrient signs: [Findings if clinically suspected]
• Overall impression: [No malnutrition / At risk / Suspected malnutrition / Meets criteria per local standard]

Medical History

• Active diagnoses and nutrition-relevant conditions: [List]
• Pertinent surgical history: [GI, bariatric, other]
• Physical activity and functional status: [Typical activity level, limitations]
• Relevant psychosocial context: [Stressors, mental health considerations impacting intake or self-management]

Estimated Needs
Energy: [kcal/day] via [equation/method] (Note weight used and activity/stress factors.)
Protein: [g/day] ([g/kg/day]; basis and rationale).
Fluid: [mL/day] (method).
Special considerations: [Fiber, sodium, potassium, carbohydrate distribution, fat type] (Include only if relevant.)
Uncertainty notes: [e.g., based on reported weight; activity level estimated]

Assessment Summary
[4–8 sentence synthesis identifying the primary nutrition problems, likely drivers, and supporting evidence from intake, anthropometrics, labs, NFPE, and symptoms. State clinical risk level and immediate priorities. Label inferences explicitly, e.g., "Likely inadequate protein intake based on [evidence]." Conclude with transition to prioritized nutrition diagnoses.]

Nutrition Diagnosis

(List diagnoses in priority order using PES format. If diagnosis cannot be supported, state: "Diagnosis cannot yet be made — Additional assessment needed: [specify missing data].")

[Diagnosis 1]

• Problem: [Standard nutrition diagnosis term]
• Etiology: [Specific, modifiable root cause]
• Signs/Symptoms: [Measurable evidence from Assessment]
• Priority Rationale: [Brief reason for priority] (Optional.)

[Diagnosis 2]

• Problem: [Standard nutrition diagnosis term]
• Etiology: [Specific, modifiable root cause]
• Signs/Symptoms: [Measurable evidence from Assessment]

(Include additional diagnoses only as supported and actionable.)

Intervention

Nutrition Prescription
[Specific dietary targets aligned with estimated needs and diagnoses: energy, macronutrient goals, fluid, sodium/fiber/micronutrient targets, meal pattern or carbohydrate distribution as relevant]

Goals (SMART)

• [Goal 1: Specific behavior/outcome, measurable target, timeframe] (Ensure jointly set with patient.)
• [Goal 2]

Education and Counseling Provided
[Topics covered and key takeaways; counseling approach used; concrete behavior strategies discussed] Teach-back: [Used / Not used]; if used: "[Patient demonstrated understanding by...]"

Recommendations

• [Specific diet behaviors to start, stop, or modify]
• [Oral nutrition supplement: product, dose, frequency] (Only if recommended.)
• [Diet modifications: texture, therapeutic pattern]
• [Self-monitoring tasks: logs, tracking methods]

Nutrition Support (Include only if enteral or parenteral nutrition is present or being considered.)

• Route and formula: [Enteral / Parenteral; product; composition]
• Dosing: [Rate, volume, schedule; initiation/advancement plan]
• Additives and flushes: [If applicable]
• Tolerance and monitoring: [GI tolerance, labs, fluid balance]

Coordination and Referrals
[Referrals placed or recommended; communication with care team members]

Patient Instructions
[Action steps before next visit; handouts or materials provided by title/topic]

Monitoring and Evaluation

Monitoring Indicators

• Indicator: [What will be measured]; Baseline: [Today's value]; Target: [Goal]; Timeframe: [When to reassess]; Data source: [Lab / food log / scale / symptom diary]
• Indicator: [What will be measured]; Baseline: [Today's value]; Target: [Goal]; Timeframe: [When to reassess]; Data source: [Lab / food log / scale / symptom diary]

Barriers and Enablers
Barriers: [Cost, schedule, access, symptoms, literacy, cultural preferences]
Enablers: [Support system, motivation, skills, resources]
Contingency plan: [If applicable]

Follow-Up Plan
[Follow-up interval] via [in person / telehealth / phone]. Patient to bring: [Food log, weight log, glucose data, new labs, etc.]. Criteria for earlier contact: [Symptoms, weight change thresholds, glycemic parameters, or other triggers warranting escalation].

(Always include: header fields, reason for consult, data sources, food/nutrition history, anthropometrics, at least one diagnosis or statement that diagnosis cannot yet be made, intervention plan, and follow-up plan. Include NFPE and Nutrition Support sections only when indicated. Use "Not available," "Not assessed," or "Patient declined" when expected data are missing. Label inferences explicitly with supporting evidence.)