ADIME Charting Format - Dietitian Direction

ADIME Format: Documenting the Nutrition Care Process

ADIME is a format of medical charting specifically for dietitians and other nutrition professionals. ADIME stands for:

A – Assessment

D – Diagnosis

I – Intervention

M – Monitoring

E – Evaluation

The ADIME charting format mimics all of the steps of the Nutrition Care Process (NCP), which was adopted by the Academy of Nutrition and Dietetics (AND) in 2003. Each section of this format has specific information to be documented.

Assessment

In the assessment section, information directly from the patient, as well as from their medical record, should be included. This includes information such as:

Anthropometric data, including weight history
Medical tests and procedures
Lab values
Medications and supplements
Medical history, which can include family history
Nutrition focused physical exam (NFPE)
Personal and social history
Food and nutrient intake by doing a 24 hour recall, usual intake and/or food frequency
Diet history
Physical activity
Patient’s knowledge, attitudes and beliefs

Diagnosis

For ADIME documentation, diagnosis does not refer to a medical diagnosis, but rather a nutrition diagnosis. This is provided in the form of a PES statement.

A PES statement identifies a nutrition problem and provides support for the finding. It is written in the following format:

[Problem/nutrition diagnosis] related to [Etiology], as evidenced by [Signs/symptoms].

An example of a PES statement is:

Excessive sodium intake related to reliance on convenience and fast foods as evidenced by an average intake of 4343 mg sodium daily, ankle edema and elevated blood pressure readings.

The nutrition diagnosis is from a list of standard terminology, found at the eNCPT website. A subscription is required to access this list.

A dietitian’s note may have just one PES statement or several. It is generally recommended to have no more than three. If a patient has no immediate nutrition-related issues, “no nutritional diagnosis at this time,” can be documented.

Intervention

The first part of the intervention section is the nutrition prescription (e.g. 1800 Calorie Sodium Modified Diet). Then the intervention is planned and implemented.

This can be documented by stating what nutrition education was provided, what counseling strategies were used, referrals to other healthcare providers and community programs were provided, etc.

Monitoring and Evaluation

The monitoring and evaluation step of the NCP is where information related to progress of the intervention is reviewed. This is where new information such as self-monitoring data, anthropometric data and labs should be documented.

Things such as patient understanding and adherence, follow through with referrals, barriers to progress, and future plans for nutrition care should be documented.

ADIME Note Example

Patient Name: John Smith

DOB: 09/12/1966

Assessment

Medical history/problem list: obesity, hypertension

Medications/supplements: 10 mg lisinopril, vitamin D (unknown dosage)

Height: 5’8”

Weight: 220

BMI: 33.45

Weight history: has gained ~20# in last 1.5 years

Laboratory values: unavailable at this time

Blood pressure: 132/88 at home this morning per patient

Diet history: “cutting back”, keto

Food allergies and intolerance: none per patient

Usual Intake:

Breakfast: 8:00 AM – coffee with ~¼ cup flavored creamer, bagel with cream cheese

Lunch: 1:30 PM – leftovers or McDouble $5 meal with regular Coke

Snack: 3:00 PM – chips from vending machine or beef stick

Dinner: 6:00 PM – ~8 oz chicken breast or steak, potato with butter and sour cream, side salad with ranch dressing; goes out to eat ~2x/wk

Snack: 9:00 PM – ice cream ~3x/wk

Beverages: one coffee per day, ~48 oz water daily, one Gatorade daily and generally has ~20 oz Coke daily; drinks alcohol ~3x/wk (2-4 beers)

Physical activity: walks dog for 5 mins 5d/wk

Diagnosis

Excessive energy intake related to intake of calorically dense foods as evidenced by regular consumption of fast food, ice cream and sweetened beverages, BMI of 33.45.

Intervention

1800 Calorie Heart Healthy Diet

Provided education on the plate method and showed patient how to track intake using an app. Helped patient set the following goals:

Start tracking intake using app suggestion provided
Bring lunch from home Monday through Friday
Try lemon water and flavored seltzer water as soda alternatives

Monitoring & Evaluation

Will monitor and evaluate at next appointment:

Weight/BMI
Blood pressure readings
Calorie intake via tracking app
Adherence to goals set at today’s appt
Intake of sweetened beverage and alcohol intake
Physical activity

Is the ADIME Format Required?

No, dietitians are not required to chart using the ADIME format. While dietitians do need to document accurately and thoroughly, it does not need to be done in a specific format.

ADIME vs SOAP

Before the creation of the ADIME format, dietitians were usually writing “SOAP notes”. This charting format is used by physicians and other healthcare providers as a way to document and is still used by some dietitians today. SOAP stands for:

S – Subjective

O – Objective

A – Assessment

P – Plan

The subjective section includes information provided by the patient. This includes things like chief complaint, medical history, and medications.

In the objective section, information such as vital signs, weight and laboratory values will be placed.

The assessment section contains the nutrition diagnosis in the form of a PES statement, as well as the nutrition prescription.

The plan section is where the nutrition intervention and goals go.

How to Incorporate the ADIME Format in Your Charting

Understanding ADIME is one thing, but actually utilizing it is another. There are a few different options in how to use it for documentation, depending on your situation.

Create Your Own Template

If you document using an Electronic Health Record (EHR), talk to your supervisor or IT department about creating an ADIME template, if you do not have one already. You, or the dietetics department as a whole, will most likely be responsible for deciding what the template contains.

If you do not use an EHR, you could create your own template. This could be a 1-2 sided sheet that has space to be filled in by hand.

Purchase Templates

Instead of reinventing the wheel, save yourself some time and use a template someone has already created.

Well Resourced Dietitian, formerly known as RD2RD, is an online marketplace for dietitians. There you will find a variety of resources for sale, including forms and templates. The website has multiple ADIME templates for sale, including an ADIME Nutrition Assessment Charting Form that is available in both PDF and Word document formats.

Use an Electronic Health Records with ADIME Templates

If you have your own business and are in control of what EHR is being used, consider using one that has pre-made ADIME templates. For example, Kalix Health is an EHR specifically made for dietitians and has an extensive template library that includes both initial and follow up ADIME templates. These templates are customizable so you can add and delete sections to fit your needs.

If you prefer using the SOAP format, Kalix has templates for that as well. Both styles of forms give you the option of copying information from last visit, so information can autofill from what was documented previously.

How I Chart in My Practice

Personally, I was mainly trained on SOAP notes during my coordinated program. I currently use a modified, and heavily customized, ADIME template within Kalix. I do not write PES statements but rather have a “clinical assessment” section where I write a collection of nutrition problems, etiologies, signs, symptoms and other statements based on my synthesis of the information.

Summary of ADIME

ADIME is a format of medical charting specifically for dietitians that follows the steps of the NCP. It is a newer style of charting that the dietetics community is not necessarily required to use, but its use is encouraged by AND.

Note that the 2023 edition of the Nutrition Care Process Terminology (eNCP) is used, which is the most current version at the time of this article being published.