Nutrition Therapy Note (ADIME)

Date of Service: [Date]

Visit Type: [Initial / Follow-up]

Time: [Start time - End time / Total face-to-face minutes]

Setting/Modality: [Inpatient / Outpatient / Telehealth; In-person / Video / Phone]

Referring Provider: [Name and reason for referral] (Omit if not applicable)

Dietitian: [Name, credentials]

Assessment

[Nutrition assessment narrative] (Document as a cohesive narrative. Include patient-stated and referral-stated concerns, data sources and reliability, current intake pattern and eating behaviors, food environment/access, relevant anthropometrics with dates and trends, pertinent biochemical data with dates, nutrition-focused physical findings if assessed, relevant medical history, medications/supplements affecting nutrition, and estimated nutrition needs with method if calculated. For initial visits, provide comprehensive baseline; for follow-ups, focus on interval changes since last encounter. Use "Not available" or "Not assessed" with brief reason when clinically important information is unavailable. Conclude with a brief summary identifying key problems, drivers, and barriers that lead into the diagnosis.)

Diagnosis

(List nutrition diagnoses in priority order using PES format. Choose modifiable etiologies and measurable signs/symptoms. For follow-up visits, include status for each diagnosis.)

1. [Problem] related to [Etiology] as evidenced by [Signs/Symptoms] (For follow-up, append: [Status: New / Active / Improving / Resolved / Discontinued with reason])
2. [Additional PES statement with status if follow-up] (Include only if applicable)

(If no actionable nutrition problem exists, document: "No nutrition diagnosis at this time" with brief rationale: [Rationale])

Intervention

Nutrition Prescription: [Dietary targets or nutrition support orders as applicable, such as macronutrient goals, restrictions, texture modifications, or enteral/parenteral regimen]

Education/Counseling: [Topics taught, materials provided, counseling approaches used, barriers addressed, and strategies developed collaboratively with patient]

Coordination: [Referrals placed, communication to other providers, resources connected] (Omit if none)

SMART Goals: [1-3 patient-centered goals with specific behavior, measurable target, and timeframe] (If patient declines goal-setting, note reason and alternative approach)

Monitoring and Evaluation

Indicators and Targets: [For each active diagnosis and goal: indicator to monitor, target value, method/source, and timeframe] (Maintain explicit linkage to signs/symptoms in PES statements)

Progress Evaluation: [Compare previous values to current; goal status: Met / Partially met / Not met; barriers/facilitators; intervention adjustments with rationale] (Include for follow-up visits only)

Follow-up Plan: [Recommended timeframe for next visit, labs or measures to obtain beforehand, discharge criteria if applicable]

(Omit sections or content not relevant to this encounter.)