Inpatient Nutrition Follow-Up Note (ADIME)

ADIME Nutrition Follow-Up

Date/Time: [Encounter date and time]

Dietitian: [Name, credentials, department]

Reason for Follow-Up: [Concise reason for reassessment]

Data Sources: [Patient interview / Chart review / Flowsheets / RN report / Care team discussion / Family input]

(Focus on interval changes and decision-driving data. Omit subsections that are not applicable. When information is unavailable, state what is missing and why.)

Interval Update

• [Diet order changes / Nutrition support modifications / NPO periods]
• [Major clinical events impacting nutrition status or plan]
• [Relevant medication changes affecting appetite, GI function, or glycemia]
• [Disposition trajectory impacting nutrition planning]

(If no significant changes, document: "No significant interval nutrition-related changes.")

Assessment

Intake/Tolerance: [Current route: PO / EN / PN] — [Adequacy vs. ordered or needs] — [Key barriers to intake] — [GI tolerance: nausea, distension, bowel function] — [Diet texture/safety status]

Weight Trend: [Current weight with date] — [Trend during admission] — [Fluid status caveats affecting interpretation]

Relevant Labs: [Trend and implication of decision-driving labs only] (Report trends and clinical implications rather than raw values.)

Estimated Needs: [Energy target with method/weight used] — [Protein target with weight basis] — [Fluid target] (If unchanged, document: "Needs unchanged; see RD note dated [date].")

Nutrition-Focused Physical Findings: [Objective findings of muscle/fat loss, edema, functional status changes] (Include only when malnutrition is being evaluated; otherwise omit.)

Diagnosis

• [Problem] related to [Etiology] as evidenced by [Measurable signs/symptoms].
• (Add additional PES statements in priority order as applicable.)

(If no active nutrition problem, document: "No nutrition diagnosis at this time" with brief rationale.)

Intervention

Plan: [Route strategy: optimize PO / continue-advance EN / initiate-consider PN] — [Prescribed targets and specific actions: diet order, ONS, EN rate/advancement, PN composition] — [Orders placed and team coordination] — [Patient/caregiver education provided]

Goals:

• [SMART Goal #1 with timeframe]
• [SMART Goal #2 with timeframe] (Include if applicable.)

Discharge Planning: [Recommended diet, oral supplements, home EN/PN setup, outpatient RD referral, key education] (Include when discharge is anticipated.)

Provider Communication: [Communication to provider regarding malnutrition diagnosis per facility policy] (Include when applicable.)

Monitoring/Evaluation

Goal Progress: [Achieved / Progressing / Not achieved / Discontinued] (Include brief reason if not achieved or discontinued.)

Monitoring Plan:

• [Indicator] → [Goal/criteria] → [Frequency]
• [Indicator] → [Goal/criteria] → [Frequency]

Follow-Up: [RD to follow in timeframe / PRN] (Include triggers for earlier reassessment if applicable.)