ADIME Note Template

What Is An ADIME Note?

ADIME is an acronym that dietitians and nutritionists use to format their clinical notes for better care. They are used to 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 mean.

Assessment

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

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• Client’s history including nutrition history, social and family history
• Client’s medical history where relevant to their diet/nutrition
• Anthropometric measurements such as height, weight, BMI, arm circumference, and past weight history
• Results of medical lab tests
• Vital signs such as resting heart rate, or other biochemical measurements.

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

Diagnosis

The 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 in order to yield a more meaningful diagnosis.

Intervention

The intervention section is for the plan for your client. Essentially, it asks what steps do you recommend for your client to address their diagnosis? This might include goals for your client, nutritional prescriptions, counseling, or educational resources.

Monitoring and Evaluation

The final section is for summing up what you will review at your next appointment, and how you will monitor your client’s progress. How will you measure your client’s progress toward their goals?

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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. It's a win-win.

How To Use ADIME Notes in 2023

This template is designed to make it easy for you to take structured and clearly 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.

1. Open the template

The template can be downloaded from the link in this page, printed out, or used right from within Carepatron. However you like to take notes, the first step is to open up your template - easy as pie!

2. Fill in your client’s information

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

3. Reason(s) for referral

We have created a dedicated space for a short summary of 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 right to the bottom of their health concerns to save time.

4. Fill in the ADIME sections

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

5. Sign the ADIME note and store it securely

The last step is to write your name, sign the note, and ensure the note is stored safely. This note contains confidential patient health information and so you have a legal requirement 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 over them again.

Who Can Use this Printable ADIME Note Template?

Our ADIME Note template was designed with Registered Dietitians and Registered Dietitian Nutritionists in mind. There are a wide variety of dietetic specialties that can benefit from using our ADIME Note templates, including:

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• 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.

Why Is This Template Useful For Registered Dietitians (RD) or Registered Dietitian Nutritionists (RDN)

Keep your notes organized

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

Structure 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. Registered Dietitians and Registered Dietitian Nutritionists 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.

Save 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.

Benefits of ADIME Notes 2023

Using a template for your clinical notes comes with many benefits for you as a practitioner, and for your practice as a whole. You can enhance the way you record client information, and get to the heart of their concerns much faster.

Improve the readability of your notes

You are likely to share these notes with several people which might include your client as well as other members of their care team. As such, it’s important this note is readable and laid out in a clear way. Our ADIME note template makes it simple for others reading your notes to understand.

Provide evidence for insurance companies

Insurance companies may require evidence of your session with your client, and sharing your notes in this easy ADIME 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.

Save time formatting

With our ADIME note template, the formatting is all done for you. All that’s left is the content, which is even easier to obtain from your client when you have a pre-made template to work with.

Monitor your client’s progress

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. Keeping the format of your notes consistent by using a template makes this even easier to do!

Ace your next clinical audit

In your clinical practice, you may be required to provide evidence of your competency or provide reasons for a clinical decision you made for a client. Having clearly laid out ADIME notes using our ADIME note template is a great start for ensuring you ace your next clinical audit.