NAME: NUTRITION CARE PROFESSIONALS

STUDENT ID:

NUTRITION PROGRESS NOTE — ADIME

i. Complete a medical-record entry (progress note) that includes the key data from the Nutrition
Assessment, Diagnosis, Intervention, and Monitoring and Evaluation Activities.

Case Study:

Assessment, Diagnosis, Intervention, Monitoring and Evaluation (ADIME)

INITIAL CONSULTATION
The template below is an example only. ADIME Documentation may be listed in any order.
Subheadings are optional.

Name/Date/Time:

Reason for Referral/Presenting Complaint/Diagnosis:

NUTRITION ASSESSMENT

Age: Height:

Weight: BMI:

Estimated Energy Needs: Estimated Protein Needs:

Other (specify): Other (specify):

Food/Nutrition-Related History

Anthropometric Measurements Biochemical Data, Medical Tests and Procedures

Physical Exam Findings Client History

nutritioncarepro.com
© Stewart, Myers 2023
NAME: NUTRITION CARE PROFESSIONALS
STUDENT ID:

Assessment, Monitoring and Evaluation Tools Comparative Standards

NUTRITION DIAGNOSIS

PES Statement(s)
Problem, Etiology, (Related to) Signs and Symptoms (As evidenced by)

Etiology Category
Beliefs/Attitudes Psychological
Cultural Social personal
Knowledge Treatment
Physical function Access
Physiologic metabolic Behavior

Etiology Category
Beliefs/Attitudes Psychological
Cultural Social personal
Knowledge Treatment
Physical function Access
Physiologic metabolic Behavior

Etiology Category
Beliefs/Attitudes Psychological
Cultural Social personal
Knowledge Treatment
Physical function Access
Physiologic metabolic Behavior

NUTRITION INTERVENTION
Aims/Goals (SMART)
Describe desired outcome of a nutrition intervention.

nutritioncarepro.com
© Stewart, Myers 2023
 NAME: NUTRITION CARE PROFESSIONALS
STUDENT ID:

Goal Progress Goal Goal Goal Goal Subject Goal Setter

Evaluation Description Target Value Timeframe

New goal identified

☐ Goal not achieved
☐ Goal achieved
☐ Goal discontinued
☐ Goal not achieved
☐ Some progress
☐ Some digression

New goal identified ☐ ☐ ☐ ☐ ☐

☐ Goal not achieved
☐ Goal achieved
☐ Goal discontinued
☐ Goal not achieved
☐ Some progress
☐ Some digression

New goal identified

☐ Goal not achieved
☐ Goal achieved
☐ Goal discontinued
☐ Goal not achieved
☐ Some progress
☐ Some digression

Nutrition Prescription

Details of Intervention/Plan Food and/or Nutrient Delivery (ND)

(Remove categories if not used)

Nutrition Education (E)

Nutrition Counseling (C)

Coordination of Nutrition Care by Nutrition Professional (RC)

Nutrition Intervention Encounter Context (IC)

NUTRITION MONITORING AND EVALUATION

Specific Indicators, Criteria and Time frame

What will you assess to evaluate effectiveness of intervention? Check those that apply. Select the important few (usually
only 3-5)

nutritioncarepro.com
© Stewart, Myers 2023
NAME: NUTRITION CARE PROFESSIONALS
STUDENT ID:

NUTRITION MONITORING AND

EVALUATION TERMINOLOGY PARAMETER INDICATOR FOR SUCCESS TIME FRAME FOR MEASUREMENT
DOMAIN(1,2)
Food/Nutrition-related History
(FH)

Medication/Alternative Medicine
Use (FH-3)

Knowledge Belief Attitude

Determination (FH-4)

Behavior Determination (FH-5)

Anthropometric
Measurements (AD)

Biochemical Data, Medical

Tests and Procedures (BD)

Physical Exam Findings (PD)

Assessment, Monitoring &

Evaluation Tools (AT)

Reminder: Save your work as a PDF before submitting to your instructor

nutritioncarepro.com
© Stewart, Myers 2023