The ADIME acronym stands for Assessment, Diagnosis, Intervention, Monitoring, and Evaluation. It’s a standardized framework developed by the Academy of Nutrition and Dietetics to guide dietitians in documenting patient care systematically. Unlike SOAP notes, which focus broadly on medical documentation, ADIME is tailored for nutrition care, emphasizing the PES statement (Problem, Etiology, Signs/Symptoms) to articulate nutrition diagnoses.
- Assessment: Gather patient data (e.g., medical history, lab results, dietary intake).
- Diagnosis: Identify nutrition problems using a PES statement.
- Intervention: Develop a targeted care plan to address the diagnosis.
- Monitoring: Track progress with measurable indicators.
- Evaluation: Assess the effectiveness of interventions and adjust as needed.
This structure ensures compliance with clinical standards and seamless integration with EHR systems like Epic, Cerner, and Athenahealth, making it ideal for hospital dietitian charting and outpatient nutrition documentation.
Adopting the ADIME documentation template offers multiple advantages for dietitians and healthcare organizations:
Improved Efficiency: Reduces documentation time by up to 75% when paired with AI medical scribes like S10.AI’s CRUSH, allowing more focus on patient care.
Enhanced Accuracy: Structured format minimizes errors, with AI tools ensuring precise medical terminology recognition (98% accuracy for general terms).
Compliance: Aligns with NCP ADIME documentation guidelines, supporting billing and regulatory requirements.
Burnout Reduction: Cuts after-hours charting, addressing the 93% of dietitians who report documentation as a burnout factor.
Interoperability: Seamlessly integrates with EHR systems (e.g., Epic, Cerner, Practice Fusion), streamlining workflows.
Specialty-Specific Customization: Tailored for renal, pediatric, diabetes, and nursing home settings, ensuring relevance across diverse patient populations.
Writing an ADIME note can feel daunting for beginners, but following these steps ensures clarity and compliance. Here’s a practical guide to crafting an easy ADIME note for beginners:
Collect comprehensive patient data, including:
Example: A 45-year-old male with Type 2 diabetes presents with a BMI of 32, HbA1c of 8.5%, and a diet high in processed carbohydrates.
Formulate a nutrition diagnosis using a PES statement:
Example PES Statement: Excessive energy intake related to frequent consumption of sugary beverages as evidenced by HbA1c of 8.5% and BMI of 32.
Design a targeted plan to address the diagnosis, including:
Example: Provide education on low-glycemic food choices, recommend reducing sugary beverages to <10% of daily intake, and schedule weekly follow-ups.
Define measurable indicators to track progress, such as:
Example: Monitor HbA1c every 3 months and weight biweekly to evaluate dietary adherence.
Assess intervention effectiveness and adjust the plan:
Example: After 3 months, HbA1c decreased to 7.8%, and BMI dropped to 30. Continue current plan with increased focus on physical activity.
Below are ADIME note examples tailored to specific patient populations, demonstrating how to apply the template in real-world settings.
Assessment: 50-year-old female, Type 2 diabetes, BMI 29, HbA1c 9.2%, reports irregular meal patterns and high-carb snacks.
Diagnosis: Inadequate carbohydrate intake control related to irregular meal timing as evidenced by HbA1c of 9.2% and frequent high-carb snacking.
Intervention: Educate on consistent carbohydrate intake (45-60g/meal), provide meal planning resources, and refer to a diabetes educator.
Monitoring: Track HbA1c quarterly, monitor daily carb intake via food diary.
Evaluation: Reassess in 3 months to evaluate HbA1c and dietary adherence.
Assessment: 60-year-old male with CKD Stage 3, serum potassium 5.5 mEq/L, reports high-potassium food intake (bananas, potatoes).
Diagnosis: Excessive potassium intake related to consumption of high-potassium foods as evidenced by serum potassium of 5.5 mEq/L.
Intervention: Educate on low-potassium diet, provide food substitution list, and coordinate with nephrology team.
Monitoring: Monitor serum potassium monthly and review food logs weekly.
Evaluation: Reassess potassium levels in 4 weeks; adjust dietary restrictions if needed.
Assessment: 8-year-old male, BMI >95th percentile, reports frequent fast-food consumption and low vegetable intake.
Diagnosis: Excessive energy intake related to frequent fast-food consumption as evidenced by BMI >95th percentile and dietary recall.
Intervention: Educate family on balanced meals, introduce kid-friendly vegetable recipes, and set goal of 2 vegetable servings/day.
Monitoring: Track BMI quarterly and vegetable intake via parental reports.
Evaluation: Reassess BMI and dietary habits in 6 months.
Assessment: 72-year-old female, post-op hip surgery, poor appetite, 10% weight loss in 1 month.
Diagnosis: Inadequate oral intake related to post-surgical appetite loss as evidenced by 10% weight loss and reduced food intake.
Intervention: Initiate high-calorie, high-protein diet, provide oral nutritional supplements, and consult with speech therapy for swallowing assessment.
Monitoring: Monitor daily caloric intake and weight weekly.
Evaluation: Reassess nutritional status in 2 weeks; adjust supplements as needed.
AI in healthcare is transforming nutrition documentation by automating repetitive tasks and improving accuracy. S10.AI’s CRUSH AI Medical Scribe, for instance, listens to patient-dietitian conversations in real-time, transcribes with 98% accuracy, and populates ADIME note templates directly into EHR systems like Epic, Cerner, and Athenahealth. Here’s how AI tools like S10.AI boost productivity and reduce burnout:
Case Study Quote: “S10.AI’s CRUSH scribe has transformed our workflow. I now spend 40% more time with patients instead of charting, and the ADIME notes are accurate and EHR-ready,” says Dr. Sarah Thompson, Clinical Dietitian at Mercy Hospital.
To maximize the impact of your ADIME documentation, follow these hospital dietitian charting best practices:
For dietitians seeking a starting point, a free printable ADIME note template PDF can be a valuable resource. Here’s a basic template you can adapt:
ADIME Note Template
FAQs About ADIME Note Templates
An ADIME note template is a structured framework for documenting the Nutrition Care Process, including Assessment, Diagnosis, Intervention, Monitoring, and Evaluation, tailored for dietitians.
Include a detailed assessment (e.g., HbA1c, BMI), a PES statement (e.g., excessive carbohydrate intake), targeted interventions (e.g., carb counting education), and specific monitoring and evaluation metrics.
Yes, AI tools like S10.AI’s CRUSH transcribe patient conversations, populate ADIME templates, and integrate with EHRs like Epic and Cerner, saving up to 75% of documentation time.
Check out S10.AI’s resource library for sample ADIME notes across specialties like diabetes, renal, and pediatrics.
The ADIME note template is a powerful tool for dietitians, streamlining nutrition documentation and ensuring compliance with clinical standards. By integrating AI medical scribes like S10.AI’s CRUSH, dietitians can reduce documentation time by 75%, combat burnout, and focus on patient-centered care. Compatible with EHR systems like Epic, Cerner, and Athenahealth,S10.AI supports all specialties, from diabetes to renal care, making it the best AIsolution for clinical nutrition documentation.
How can I efficiently structure an ADIME note for a complex patient with multiple nutritional issues?
For a complex patient, a well-structured ADIME note is crucial for clarity and continuity of care. Start with a comprehensive "Assessment" section, detailing anthropometrics, relevant medical and diet history, and biochemical data. In the "Diagnosis" section, formulate multiple PES statements if necessary, prioritizing the most critical nutritional problems. Your "Intervention" should then directly address each diagnosis with specific, evidence-based strategies, such as dietary modifications, nutrition education, and coordination with other healthcare providers. Finally, the "Monitoring and Evaluation" section should outline clear, measurable goals to track progress for each issue. To streamline this process and ensure no detail is missed, consider implementing an AI scribe that can automatically populate an ADIME template from your patient conversations.
What is the most effective way to write a PES statement in an ADIME note to ensure a clear and actionable nutrition diagnosis?
The key to an effective PES statement is to be precise and evidence-based. The "Problem" (P) should be a specific nutrition diagnosis from standardized terminology. The "Etiology" (E) must identify the root cause of the problem, which will guide your intervention. The "Signs and Symptoms" (S) should be the objective and subjective data from your assessment that provide evidence for the diagnosis. For instance, a strong PES statement would be: "Inadequate energy intake (P) related to decreased appetite and early satiety (E) as evidenced by daily caloric intake of 1200 kcal, a 5% weight loss over the last month, and patient reporting feeling full after small meals (S)." Explore how AI-powered tools can help you generate accurate and well-formed PES statements based on your assessment data.
How do I decide whether to use an ADIME note versus a SOAP note for my nutrition documentation?
The choice between an ADIME and a SOAP note depends on your practice setting and the level of detail required. ADIME notes are the standard in dietetics, offering a structured and comprehensive framework for the entire nutrition care process, from assessment to evaluation. They are ideal for dedicated nutrition consultations and for tracking patient progress over time. SOAP notes, on the other hand, are more widely used across various healthcare disciplines and are suitable for interdisciplinary communication or for brief progress updates. If you find yourself needing to create both for different purposes, learn more about AI scribes that can instantly transform your ADIME note into a SOAP note, saving you valuable documentation time.
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