ADIME Progress Note- Template Only

Name:

Disease State: Weight management

Name/Date/Time:

Follow-up Consultation For: Weight management and diabetes education

NUTRITION MONITORING AND EVALUATION *9

Weight: 150.1 kg (330 lb) BMI: 53.86

Height: 1.67 m (5’5”)

Estimated Energy Needs: Based on her current weight 2700

Estimated Protein Needs: Based on her ideal weight: 67-85

Food/Nutrition-Related History Anthropometric Measures

She has had a decreased appetite for the last 2 Patient is 5’5” and weighs 330 lb. Her current BMI is 53.86. Her
weeks due to nausea and vomiting. ideal body weight is 125 lbs.

Biochemical Data, Medical Tests and Procedures Nutrition-Focused Physical Findings

BG POC 227-253 mg/dL x 24 hours. A1c 10.5% No NFPE was performed at this visit.

Client History Comparative Standards

Asthma, hypertension, GERD, 18 kcal/kg and protein is based on IBW.
heavy menstrual bleeding, and
type 2 diabetes. 1.2-1.5 based on IBW

CURRENT NUTRITION DIAGNOSIS

PES Statement(s) Altered nutrition related lab value related to endocrine as
evidenced by BG POC 227-253 mg/dL x 24 hours and A1c 10.5%

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Problem, Etiology, Signs Food and Nutrition related knowledge deficit related to lack of
and Symptoms prior knowledge as evidenced by needing carbohydrate counting
education.

NUTRITION INTERVENTION
Nutrition Prescription Change in lifestyle to better control diabetes and weight.

Aims/Goals (SMART) Decrease caloric intake to help with weight loss and started
counting calories to help control diabetes.

Detail of Intervention/Plan Decrease caloric intake by 500 kcal and try to maintain 255 gm
carbohydrate consent diet.

NUTRITION MONITORING AND EVALUATION

Tick all that apply Food/Nutrient/Energy Nutrition Assessment/Monitoring and Evaluation
Tools
Anthropometrics
Labs (specify)
Behavior or
Knowledge/Beliefs/Attitudes
Specific Indicators, This patient is classified as a low/moderate. This means the patient will be seen in 5 days.
Criteria and Time
frame

What will you assess

during follow-up
consultations?

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Also Complete a Narrative ADIME Note for the same patient with the following Format:

Nutrition Assessment:

Patient came to the hospital after having a low hemoglobin of 5.2. She has a history of anemia, hypertension,

dysfunctional uterine bleeding, diabetes, and currently having 6 months of vaginal bleeding. In the last 2 weeks she has

experienced decreased appetite due to nausea and vomiting resulting in a 10 lb wt loss. The patient states at home she

drinks 1 Glucerna a day.

Nutrition Diagnosis:

Altered nutrition related lab value related to endocrine as evidenced by BG POC 227-253 mg/dL x 24 hours and A1c
10.5%

Food and Nutrition related knowledge deficit related to lack of prior knowledge as evidenced by needing carbohydrate
counting education.

Nutrition Intervention:

Recommend 255 gm carbohydrate consistent diet and counting her carbohydrates. Also recommend patient decreases

caloric intake by 550 kcal to help with weight loss. Pt was provided with the proper education to help with both counting

carbohydrates and weight loss. Will refer this patient to an outpatient dietitian and possible bariatric.

Nutrition Monitoring/Evaluation:

For this patient I would monitor patients’ food and nutrition intake, as well as tests and procedures. This patient is
classified as a low/moderate.

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