Professional Documents
Culture Documents
Classroom Activities
Activity 6-1
Items needed: None.
Conduct an oral in-class quiz over the format of SOAP note charting. Ask students which category in SOAP notes
the following items would be placed in.
The answers are listed at the end of each item (subjective = s, objective = o, assessment = a, plan = p).
© 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
Activity 6-2
Items needed: None.
Explain to students that they will now practice writing short-term goals and expected outcomes for each goal for the
following scenario. Remind students that each outcome needs to be measurable, include a specified timeframe,
indicate how it will be measured, and encourage client participation when possible.
Scenario: Josie has been identified as being at high risk for developing anorexia nervosa. Her estimated kcalorie
needs are 2350-2500 kcalories per day. A diet analysis indicates her average daily intake for the past week has been
approximately 1200 kcalories per day (approximately 50% of her needs). Her weight has been steadily decreasing
for the past two months. She states she enjoys consuming dairy products more than any other foods and often eats
only dairy products. Josie has been referred to a registered dietitian for nutrition therapy in addition to seeing a
psychologist who specializes in eating disorders.
Possible outcomes:
• Patient will keep a food diary, recording all foods eaten, and a nutrition analysis will be completed at the next
dietitian visit.
• Patient will consume foods from at least two food groups at each meal and snack in addition to foods from the
dairy group.
© 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
Handout 6: Examples of SOAP and ADIME Documentation
SOAP Format
Subjective data: diet, medical, psychosocial, and other pertinent data obtained from patient or caregiver
Objective data: anthropometric measures, lab values, and other clinical findings
Assessment: Nutrition diagnosis based on subjective and objective data; stated as nutrition “problem” related to
“etiology” as evidenced by” signs and symptoms” (PES statement)
Plan: Intervention using standardized language that helps change or resolve the nutrition problem; includes food or
nutrient delivery, nutrition education, nutrition counseling, and coordination of care
ADIME Format (from American Dietetic Association Nutrition, Diagnosis and Intervention: Standardized
Language for the Nutrition Care Process, 2007 and International Dietetics & Nutrition Terminology (IDNT)
Reference Manual, 2008)
Assessment: Relevant data used to determine whether a nutrition diagnosis/problem exists; includes pertinent
medical and psychosocial history, anthropometric, and lab data.
Diagnosis: Identifies the specific nutrition problem (diagnosis) that can be resolved or improved through nutrition
intervention. Documented in a “PES” statement: “problem” related to “etiology” as evidenced by “signs and
symptoms.” Uses standardized language and addresses at least one of three nutrition diagnoses categories: Intake,
Clinical, or Behavioral-Environmental.
Intervention: Specific treatment goals to resolve or improve the identified nutrition problem. Includes appropriate
interventions tailored to the patient’s/client’s needs.
Monitoring and Evaluation: Determines the amount of progress made and if goals or expected outcomes are being
met. Includes monitoring, measuring, and evaluating changes in patient’s behavior, nutritional status, or other
indicators of nutrition care and plans for future nutrition care.
© 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
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