Facebook tracking pixel
Back to Templates
Nutritionist
15-20 minutes

Assessment, Diagnosis, Intervention, Monitoring, and Evaluation

The ADIME template by s10.ai is an all-encompassing documentation tool designed for dietitians to evaluate, diagnose, intervene, and monitor patients' nutritional health. This template is perfect for dietitians aiming to develop comprehensive nutrition care plans, incorporating dietary assessments, weight management strategies, and lifestyle changes. It addresses various elements such as anthropometrics, dietary habits, physical activity, and lifestyle factors, ensuring a thorough approach to patient care. The ADIME template is especially beneficial for tracking progress and establishing SMART goals, making it an indispensable asset for successful nutrition management.

2,577 uses
4.4/5.0
J
James Carter
Template Structure

Organized sections for comprehensive clinical documentation

Reason for visit: [patient's reason for visit and/or chief concern]
Assessment:
- [Patient's gender, age, birthday]
- [Patient's personal history: medical, family, and social history]
- [Anthropometrics: height, weight, BMI, weight history, including changes and ideal body weight based on Hamwi equation]
- [Weight history: current weight goals, describe weight trajectory including amount of weight lost/gain over time (only include if applicable)]
- [GI: bowel movement quality and frequency, any GI symptoms (only include if applicable)]
- [Nutrition-focused physical findings: muscle and fat assessment, fluid assessment, skin turgor (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)]
Medications:
- [list medications and dosage (only include if applicable)]
Supplements:
- [list supplements and frequency consumed (only include if applicable)]
[Biochemical data: lab results, medical test outcomes (only include if applicable)]
Diet pattern: [List number of meals and snacks eaten a day]
[Diet recall that includes breakfast, lunch, dinner, snacks, beverages, and water intake]
- [Diet history: dietary intake, food preferences, food allergies, food security (only include if applicable)]
- [Previous diet attempts (only include if applicable)]
- [Describe any disordered eating thoughts or behaviors, such as emotional eating, disorganized eating schedule, mindless eating, past or ongoing eating disorders, yo-yo dieting, etc. (only include if applicable)]
Physical activity:
- [Physical activity history. Include type of activity, exercise duration, and how many times a week (only include if applicable)]
- [Physical limitations and past/existing injuries (only include if applicable)]
- [Mention any exercises the patient expresses interest in (only include if applicable)]
Lifestyle/social factors:
- [Occupation: job title, work schedule, WFH/hybrid schedule/work onsite (only include if applicable)]
- [Sleep quality: rate sleep quality as good, bad, or fair. Hours of sleep a night. Mention any sleep disruptions, loud snoring (only include if applicable)]
- [Stress levels: describe stress levels and stress management techniques (only include if applicable)]
Summary:
[Provide a summary in paragraph form]
Diagnosis:
- [Nutrition diagnosis based on assessment data (only include if explicitly mentioned and insert relevant ICD-10 code)]
- [PES statement: Problem, Etiology, Signs and Symptoms (only include if explicitly mentioned)]
Intervention:
- [Nutrition prescription tailored to the patient's needs and goals (only include if applicable)]
- [Food and/or nutrient delivery: any dietary changes, supplementation (only include if applicable)]
- [Education discussed on specific nutrition guidelines, physical activity, health behaviors]
- [Counseling: strategies to guide the patient towards health priorities (only include if applicable)]
- [Coordination of nutrition care with other healthcare professionals if needed (only include if applicable)]
- [SMART goals]
Monitoring and Evaluation:
- [Progress evaluation: tracking physical activity, food intake, symptoms, lab values (only include if applicable)]
- [Follow-up care: deciding if and when a follow-up appointment is needed (only include if applicable)]
Sample Clinical Note

Example of completed documentation using this template

Reason for visit: Patient is seeking advice on weight management and enhancing overall nutrition.
Assessment:
- Female, 35 years old, born on 15 March 1989
- Personal history: No significant medical history, family history of diabetes, non-smoker, occasional alcohol use
- Anthropometrics: Height 165 cm, weight 70 kg, BMI 25.7, weight history includes a gain of 5 kg over the past year, ideal body weight 61 kg based on Hamwi equation
- Weight history: Current goal is to lose 5 kg over the next 6 months
- GI: Regular bowel movements, no GI symptoms reported
- Nutrition-focused physical findings: Normal muscle and fat assessment, good skin turgor
Medications:
- None
Supplements:
- Multivitamin daily
Biochemical data: Normal blood glucose levels, slightly elevated cholesterol
Diet pattern: 3 meals and 2 snacks per day
Diet recall: Breakfast includes oatmeal and fruit, lunch is a salad with chicken, dinner is grilled fish with vegetables, snacks include nuts and yogurt, drinks 2 litres of water daily
- Diet history: Prefers vegetarian meals, no food allergies, food secure
- Previous diet attempts: Tried low-carb diet in the past
- Disordered eating: Occasional emotional eating during stress
Physical activity:
- Physical activity history: Jogging for 30 minutes, 3 times a week
- Physical limitations: None
- Interested in starting yoga
Lifestyle/social factors:
- Occupation: Marketing manager, hybrid work schedule
- Sleep quality: Fair, 6 hours per night, occasional disruptions
- Stress levels: Moderate, manages stress through meditation
Summary: The patient is a 35-year-old female seeking nutritional advice for weight management. She has a family history of diabetes and has gained 5 kg over the past year. Her current goal is to lose 5 kg in 6 months. She maintains a balanced diet and regular physical activity but experiences occasional emotional eating. She is interested in incorporating yoga into her routine.
Diagnosis:
- Nutrition diagnosis: Overweight (ICD-10: E66.3)
- PES statement: Overweight related to excessive caloric intake as evidenced by BMI of 25.7 and recent weight gain
Intervention:
- Nutrition prescription: Reduce daily caloric intake by 500 kcal
- Food and/or nutrient delivery: Increase intake of fruits and vegetables, reduce processed foods
- Education discussed on specific nutrition guidelines, physical activity, health behaviors
- Counseling: Strategies to manage emotional eating and stress
- Coordination of nutrition care with other healthcare professionals if needed
- SMART goals: Lose 5 kg in 6 months by reducing caloric intake and increasing physical activity
Monitoring and Evaluation:
- Progress evaluation: Track weight, dietary intake, and physical activity
- Follow-up care: Schedule follow-up appointment in 3 months
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline patient assessments and enhance healthcare delivery by integrating high-search healthcare and clinical keywords. It meticulously captures the patient's reason for visit and chief concerns, providing a structured assessment that includes personal history, anthropometrics, and nutrition-focused physical findings. Clinicians can document medications, supplements, and biochemical data, ensuring a holistic view of the patient's health. The template also covers diet patterns, physical activity, and lifestyle factors, offering insights into the patient's daily habits and potential areas for intervention. With sections dedicated to diagnosis, intervention, and monitoring, this template supports the development of personalized nutrition prescriptions and SMART goals, facilitating effective patient management and follow-up care. By adopting this template, healthcare professionals can enhance patient engagement, improve clinical outcomes, and ensure coordinated care across multidisciplinary teams. Explore this template to optimize your clinical documentation and patient care strategies today.
Frequently Asked Questions

Common questions about this template and its usage

Ready to transform your practice?

Join thousands of clinicians already using S10.AI to reduce administrative burden and improve patient care.

Assessment, Diagnosis, Intervention, Monitoring, and Evaluation