ADIME Note Template

What is an ADIME note?

ADIME is an acronym that dietitians and nutritionists use to format their clinical notes during the Nutrition Care Process (NCP) for better care. They assess a client's nutrition or diet health and contain valuable information to make appropriate diagnoses and intervention plans. ADIME stands for Assessment, Diagnosis, Intervention, and Monitoring and Evaluation, which form the four main sections of the ADIME notes. Let's take a look at what each of these headings means.

Assessment

The nutrition assessment section is for the information you gather on your client. This might include:

• Client’s social and family history
• Client's food/nutrition-related history
• Client’s medical history relevant to their diet/nutrition
• Anthropometric measurements such as height, weight, BMI, arm circumference, past weight history, and usual body weight
• Results of medical tests, biochemical data, and other nutrition-focused physical findings
• Vital signs such as resting heart rate or other biochemical measurements

You can also include subjective data, such as your patient’s feelings or self-reporting of their history, and objective data, such as measurements or lab results.

Diagnosis

The nutrition diagnosis section is for you to write your conclusion of your client’s primary nutritional concern. This should be supported by evidence gathered in the assessment section to yield a more meaningful medical diagnosis.

Intervention

The nutrition intervention section is for your client's plan. Essentially, it asks what steps you recommend for your client to address their diagnosis, whether inadequate oral intake, nutrition support with oral nutrition supplements, or having limited nutrition-related knowledge. Typical categories of nutrition interventions might include food/nutrient delivery, goals, nutritional prescriptions, nutrition counseling, or nutrition education.

Monitoring and evaluation

The final section, nutrition monitoring and nutrition evaluation, sums up what you will review at your next appointment and how you will monitor your client’s progress. One example of conducting evaluation is utilizing tools like the Nutrition Focused Physical Exam (NFPE), which aids in evaluating changes in muscle or fat related to weight loss.

You might sometimes see these sections split into five sections or with sub-headings under the main ADIME headings. To keep this template simple, we have provided the four widely recognized ADIME headings and left enough space for you to write your nutrition notes in your preferred style.

How to use our ADIME Note Template?

This ADIME Note Template is designed to facilitate the taking of structured and formatted nutritionist notes according to the well-known and up-to-date ADIME note structure. Follow these simple steps to start using this template in your nutrition practice.

Step 1: Open the template

The template can be downloaded from the link on this page, printed out, or used right from within Carepatron. However you like to take notes, the first step is to open your template. And if you need a guide on how to fill it out, consider downloading our ADIME note example as well.

Step 2:  Fill in your client's information

Each ADIME note needs to include your client's name, birth date, and the date and time of their session. Make sure to double-check this information to ensure it is accurate and free from mistakes.

Step 3.: Reason(s) for referral

We have created a dedicated space to summarize your patient's reason for referral to you as a dietitian or nutritionist. This allows for a quick version of their primary complaint rather than a comprehensive history. That way, you can get to the bottom of their health concerns to save time.

Step 4: Fill out the ADIME sections

The ADIME headings have already been set out for you. Work through these sections with your client and fill out each area appropriately, with sufficient information to guide effective treatment plans.

Step 5: Sign the ADIME note and store it securely

The last step is to write your name, sign the note, and ensure it is stored safely. This note contains confidential patient health information, and you are legally required to ensure it is stored securely. Having it located in a dedicated space also allows for all your ADIME notes to be accessible for your follow-up appointments or when you need to read them again.

Who can use this printable ADIME Note Template?

Our ADIME Note Template was designed with registered dietitians (RD) and registered dietitian nutritionists (RDN) in mind. There are a wide variety of dietetic specialties that can benefit from using our ADIME Note templates, including:

• Pediatric nutrition
• Sports dietetics
• Obesity and weight loss nutrition
• Oncology nutrition
• Geriatric nutrition
• Public health nutrition

Additionally, student nutritionists can also benefit from using this template in their training, and it provides great evidence for clinical sign-offs. ADIME notes are very useful for reflecting on your client's progress. You can compare different sections across time for the same patient or reflect on your clinical practice as a whole and compare sections across your different patients.

Benefits of this ADIME Note Template

There are a number of reasons why using an ADIME Note Template is useful. Here are some of them.

Keeps your notes organized

Having a template that separates the key information into easy-to-find sections makes it simple to keep your clinical notes organized. As an RD or RDN, you will have many clients with different needs. Using a template for your ADIME notes is the best way to standardize your ADIME note-taking and ensure you are providing comprehensive clinical notes for all your clients.

Structures your client's session

This ADIME Note Template not only serves as a structure for your notes but can also be a great way to structure your client's session with you. RD or RDNs may see clients for a whole range of reasons, but incorporating a structure to your sessions can help you capture all the important information you need during your session.

Saves time

Templates are an easy and effective way to standardize your note-taking practice. Keeping organized and having a set method for taking client notes in your nutrition or dietitian practice will reap many benefits, including saving you time.

Improves the readability of your notes

You are likely to share these notes with several people, including your client and other members of their care team. As such, this note must be readable and laid out transparently. Our template makes it simple for others reading your notes to understand.

Provides evidence for insurance companies

Insurance companies may require evidence of your session with your client, and sharing your notes in this easy note template will give them polished and readable evidence of your clinical decision-making. It is much more robust and enhances the credibility of your services.