Inpatient Nutrition Consultation Note (ADIME)

Date/Time of Assessment: [Date and time patient seen]
Dietitian: [RDN name and credentials]
Consult Ordered By: [Ordering provider/service]
Consult Reason: [Reason for consultation]
Patient Location: [Unit and level of care]
Clinical Context: [One-line summary of admission reason and key nutrition-relevant issues] (Optional; include if it adds clarity)

Assessment

Data sources and limitations: [Sources used and any assessment barriers] (e.g., EHR, nursing records, calorie counts, patient/caregiver interview, prior records. Note barriers and surrogate information used if applicable.)

Current nutrition orders:

• [Diet order with texture/consistency modifications, restrictions, precautions, NPO status]
• [Oral nutrition supplements with type and frequency] (Only include if ordered)

Oral intake and tolerance:

• [Appetite and qualitative intake pattern]
• [Quantified intake estimate with timeframe and source] (e.g., nursing meal percentages, calorie counts, patient report)
• [Tolerance and barriers] (e.g., nausea, vomiting, diarrhea, constipation, early satiety, dysphagia, pain)
• [GI function] (Bowel sounds, stool output/consistency, NG output) (Only include if relevant)

Enteral nutrition: (Only include this section if currently receiving EN)

• [Feeding access type and placement date]
• [Formula, caloric density, protein content]
• [Rate/schedule and advancement plan] (Continuous, cyclic, or bolus)
• [Free water flushes and total daily volume]
• [Delivered versus ordered and interruptions] (If known)
• [Tolerance indicators] (Residuals, emesis, abdominal distention, bowel function)

Parenteral nutrition: (Only include this section if currently receiving PN)

• [Access route and catheter type]
• [Composition summary] (Volume/day, dextrose g, amino acids g, lipids g or %)
• [Infusion rate/cycle and current status]
• [Additives] (Electrolytes, multivitamins, trace elements)

Anthropometrics:

• [Height with source] (Measured, stated, estimated)
• [Current weight with date and source] (Standing scale, bed scale, stated)
• [Weight trend with dated data points] (During admission and pre-admission if available)
• [BMI] (Include dosing weight if different from actual)
• [Fluid status confounders] (Edema, ascites, large fluid shifts) (Only include if present)

Relevant medical and social history:

• [Conditions affecting nutrition risk/needs/tolerance] (e.g., critical illness, surgery, CKD/dialysis, liver disease, GI pathology, oncology, wounds)
• [Social factors affecting nutrition/discharge] (Food access, caregiver support, ability to obtain supplies) (Only include if identified)

Laboratory data:

• [Electrolytes with trends] (K, Mg, Phos; note refeeding risk if present)
• [Glucose trends and management]
• [Renal and hepatic markers] (If relevant)
• [Other nutrition-relevant labs] (Triglycerides, micronutrients) (If available and relevant)

Medications impacting nutrition:

• [Glycemic agents] (Insulin regimen, steroids)
• [GI agents] (Prokinetics, antiemetics, bowel regimen)
• [Vasoactive agents/sedation] (Note propofol kcal/day if applicable)
• [Current vitamin/mineral supplements]

Nutrition-focused physical exam: [Completed / Partially completed / Deferred] (State reason if deferred or limited)

• [Muscle loss] (Sites and severity: temporal, clavicular, deltoid, scapular, interosseous, quadriceps)
• [Subcutaneous fat loss] (Sites and severity: orbital, buccal, triceps)
• [Fluid accumulation] (Generalized or localized)
• [Micronutrient deficiency signs] (Only include if suspected)

Malnutrition assessment:

• [Nutrition screening result] (If available)
• [Malnutrition determination: Meets criteria / Does not meet criteria / At risk]
• [Etiology context] (Acute illness/injury, chronic illness, or social/environmental) (Only include if criteria met)
• [Severity: Moderate / Severe] (Only include if criteria met)
• [Supporting characteristics with data] (e.g., weight loss %, energy intake %, NFPE findings with dates/amounts)
• [Additional data needed] (Only include if at risk with pending information)

Estimated nutrition needs:

• [Energy: X kcal/day] (State method, equation, and weight basis)
• [Protein: X g/day (X g/kg/day)] (State dosing weight approach)
• [Fluid: X mL/day] (Only include if relevant; note clinical constraints)

Intake adequacy: [Total intake from all sources vs estimated needs over specified timeframe, as absolute values and % of goal. Conclusion: Adequate / Inadequate / Unable to determine. Primary drivers if inadequate.]

Diagnosis

(List 1–3 prioritized PES statements with signs/symptoms matching documented assessment data)

• [Nutrition diagnosis term] related to [specific modifiable etiology] as evidenced by [measurable signs/symptoms with dates/amounts]
• [Additional diagnosis if applicable]
• [Additional diagnosis if applicable]

(If no active nutrition problem: "No nutrition diagnosis at this time" with brief justification)

Intervention

Nutrition prescription: [Concise prescription with route, calorie/protein targets, and restrictions aligned to estimated needs and clinical constraints]

Recommendations:

• [Diet order changes] (Texture, consistency, restrictions, precautions)
• [Oral nutrition supplements] (Type, frequency, rationale)
• [Micronutrient supplementation] (Dose, duration, indication) (Only include if indicated)
• [Enteral nutrition plan] (Formula rationale, advancement schedule, water flushes, hold minimization) (Only include if EN indicated)
• [Parenteral nutrition plan] (Macronutrient targets, cycling, micronutrients, pharmacy coordination) (Only include if PN indicated)

Orders placed: [Orders placed by RDN per policy, or "No RDN-driven orders placed"]

Education:

• [Learner] (Patient/caregiver) and [readiness/barriers]
• [Topics covered and method]
• [If deferred: reason and plan]

Communication with care team: [Who contacted, when, and content communicated] (Malnutrition status, feeding recommendations, refeeding risk, safety concerns)

Goals:

• [Intake target] (e.g., ≥X% of estimated needs by timeframe)
• [Tolerance target] (e.g., tolerate current regimen without emesis by timeframe)
• [Anthropometric target] (e.g., weight stable or gain X kg over timeframe)
• [Lab/safety target] (e.g., electrolytes within range during advancement)
• [Wound/functional target] (Only include if applicable)

Discharge nutrition considerations:

• [Anticipated discharge diet and texture]
• [Outpatient RD or specialty follow-up needs]
• [EN/PN at discharge: training needs, formula/supply arrangements, DME coordination] (Only include if applicable)
• [Food access resources and referrals] (Only include if barriers identified)

Monitoring and Evaluation

• Intake/delivery: [Meal intake % or EN/PN delivered vs ordered] target ≥[X]% by [timeframe]
• Tolerance: [GI symptoms, residuals, stool output] within [targets] by [timeframe]
• Anthropometrics: [Weight monitoring schedule and expected trend]
• Biochemical/safety: [Electrolytes, glucose, triglycerides] within [ranges] per [monitoring schedule]
• Clinical outcomes: [Wound healing, diet advancement readiness, decreased nutrition risk] by [timeframe] (Only include if applicable)

Follow-up: [RD follow-up timing] (e.g., within X hours/days or per unit protocol). Reassess earlier if: [trigger conditions] (e.g., vasopressor changes, prolonged NPO, feeding intolerance, procedures)

Signature: [Name, credentials, contact information]