ADIME Note Template with Examples

ADIME Note Template

This AI-enabled ADIME template is a comprehensive documentation tool used by dietitians to create detailed nutrition care plans, including dietary assessments, weight management strategies, and lifestyle modifications. Additionally, this template allows them to:

• Capture essential patient details, including their medical and weight history, to serve as the basis for creating an effective and personalized nutrition care plan. 
• Identify nutrition-focused physical findings, diet patterns, diet history, and instances of disordered eating.
• Outline biochemical data, medication use, and supplement intake to assess their potential nutritional impact.
  
  

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What is an ADIME Note Template?

An ADIME (Assessment, Diagnosis, Intervention, Monitoring, and Evaluation) note template is a structured documentation tool used by dietitians to assess, diagnose, monitor, and evaluate a patient’s nutritional status. It serves as a framework for collecting essential patient data, guiding the development of personalized nutrition care intervention plans to support the patient’s overall health and well-being.

In this article, we’ll discuss the importance of ADIME note templates in nutritional care, provide advice on when to use ADIME notes versus other nutrition documentation methods, share a step-by-step guide to writing effective ADIME notes along with examples, and most importantly, provide ready-to-use, AI-enabled templates you can use in your daily practice. 

Why are ADIME Note Templates Important? 

ADIME note templates are important because they provide a systematic and organized framework for documenting nutritional information, ensuring consistency and thoroughness.

Clear and well-structured documentation enhances continuity of care, improves communication between healthcare providers, and strengthens the effectiveness of personalized nutrition care plans.  

When to Use ADIME Notes vs. Other Nutrition Documentation Methods

While ADIME notes are widely used for nutritional documentation, other templates may actually be more suitable in specific situations. Let’s talk about alternative documentation methods and when they might be more preferable to ADIME notes:

Alternative Nutrition Documentation Methods

SOAP Notes (Subjective, Objective, Assessment, Plan)‍

Commonly used for interdisciplinary communication, SOAP notes are great for brief and focused documentation. However, they often lack the structured diagnosis and intervention framework that ADIME note templates offer, making them less comprehensive for nutrition cases. 

PES Statements (Problem, Etiology, Signs or Symptoms)‍

PES statements focus mainly on identifying a single nutritional problem (P), its cause (E), and its signs/symptoms (S). They are more concise than ADIME notes, and typically appear within the diagnosis section of ADIME note templates. They are sometimes used as standalone documents until it’s deemed necessary to create a more comprehensive ADIME note.

When to Use ADIME Notes

It’s best to use an ADIME note template if you’re looking to create comprehensive patient assessments that require standardized documentation. This is because the structured nature of ADIME notes ensures continuity of care, and makes it easier to track long-term patient progress.

When to Use Other Documentation Methods

SOAP notes are best when working with a multidisciplinary team, as most other healthcare professionals are familiar with its structure and format. ADIME notes, in contrast, are more widely used in nutritional healthcare settings, so they may not be widely recognized outside of dietetics. 

‍PES statements are ideal for quickly documenting a single nutrition diagnosis without additional intervention details. They are often used for initial screenings or brief consultations before developing a more detailed ADIME note if necessary.

For Dr. Chris Bojrab and the Indiana Health Group (IHG), the documentation dilemma was “madly typing or actually listening.” He shares, “Before, I had to choose between having a crappy note or sacrificing the face-to-face experience with patients,” explains Dr. Bojrab.

Five months after first using Heidi, IHG has documented over 12,000 patient consultations through the platform, and saved approximately 120,000 minutes in documentation time. This translates to roughly $200,000 in recovered clinical time value!

"It's improved our clinician-patient experience significantly," Dr. Bojrab shares. "It allows me to build a better note but at the same time actually talk to my patient more conversationally, be more present in the moment and still wind up with a good note."

Step-by-Step Guide to Writing an Effective ADIME Note with Examples

A well-structured ADIME note is crucial for delivering effective patient care, and ensuring seamless collaboration between healthcare providers. This guide will give you a detailed breakdown of each ADIME section, along with examples to help illustrate best practices when writing your own notes:

Assessment (A)‍

The opening section gathers and documents all relevant patient data, which includes the following:

• Anthropometrics (height, weight, BMI, weight history)
• Medical history (past diagnoses, medications, lab results)
• Lifestyle factors (diet, eating patterns, exercise routines, sleep quality)

Example Entry:

“Patient is a 35-year old female with a BMI of 25.7, reporting a weight gain of 5 kg over the past year. She follows a balanced diet but experiences occasional emotional eating during stress. No reported GI issues, and she maintains regular physical activity.” ‍

Diagnosis (D)‍

The second section aims to identify and define the nutrition-related problem using a PES statement (Problem, Etiology, Signs/Symptoms).

Example Entry:

“Overweight due to excessive caloric intake as evidenced by BMI of 25.7 and a weight gain of 5 kg over the past year.” 

‍Intervention (I)‍

The third section details the nutrition care plan for the patient based on their diagnosis. Common intervention methods include:

• Nutrition prescription (reduce caloric intake)
• Nutrient delivery (consume more fruits and vegetables) 
• Education (discuss portion control and mindful eating strategies)
• Coordination of care (refer to physical therapist for exercise recommendations)
• SMART goals (Lose 5 kg in 6 months by reducing caloric intake and increasing physical activity)

Example Entry:

“Recommended reducing daily caloric intake by 500 kcal, increasing fiber intake through whole grains and vegetables, and minimizing processed foods. Discussed mindful eating techniques to manage stress-related eating and set a goal to incorporate yoga twice a week.”‍

Monitoring and Evaluation (ME)‍

The final section sets measurable goals, and defines how the patient’s progress will be tracked. Common entries for monitoring and evaluation include:

• Progress evaluation (weight, diet, and physical activity tracking)
• Follow-up care (schedule for follow-up appointment)
• Reassessment criteria (assess weight trends, dietary adherence, and emotional eating patterns)

Example Entry:

“Monitor patient’s weight, dietary intake, and physical activity levels. Follow-up scheduled in 3 months to assess progress toward a 5 kg weight loss goal, and evaluate adherence to mindful eating strategies.” 

ADIME Note Template Example

Manually filling out ADIME note templates using paper or electronic forms is common practice, but they’re not the best. Errors, inconsistencies, and missed details are all issues prevalent during manual form completion.

Thankfully, our AI-powered solution can give you a faster and more accurate way to create ADIME notes, allowing you to save time and focus on your patients rather than paperwork. 

Easily Complete ADIME Note Templates with Heidi 

Heidi is our cutting-edge AI medical scribe designed to help dietitians complete ADIME templates in real-time. With your patient’s permission, simply hit record and let Heidi work as you go. Here’s how Heidi helps you complete your ADIME notes:

• Transcribe – Open Heidi on your computer or mobile device and press Start so Heidi can capture your conversation in the background. For information that you don’t want to verbalize, you can type them under context notes to be considered later.
• Customize – Post-session, simply select your preferred ADIME note template and watch as Heidi perfectly transcribes the details of your conversation and context notes in the appropriate format!
• Transform – After generating your completed ADIME note, you can ask Heidi to give additional documentation including SOAP notes and patient summary notes as needed. 

Heidi complies with jurisdiction-specific regulations, ensuring data localization for customers in Australia, Canada, the United States, the United Kingdom, and beyond. Read more about our compliance here.

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Free ADIME Note Templates

ADIME Format Note Template

This ADIME format note template helps medical nutrition specialists document essential patient data to inform effective nutritional interventions. It includes fields for recording assessment information, the results of a nutrition focused physical exam (NFPE), daily estimated nutrition needs, and monitoring and evaluation plans, among others. 

View Template

ADIME Follow Up Note Template

This ADIME follow-up note template helps nutritionists document their patient’s nutritional assessment, physical exam findings, medical history, medical test results, and nutritional diagnosis, including a PES statement. It also includes a field for nutrition monitoring and evaluation, along with measurable goals and time frames to observe patient progress. 

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FAQs About ADIME Note Templates

What are the four key points of ADIME note templates?

The four key points or sections are Assessment, Diagnosis, Intervention, and Monitoring and Evaluation. Together, they provide a system for structuring patient data, identifying nutrition-related problems, and developing personalized nutrition care plans for patients. 

How do AI medical scribes compare to paper-based ADIME note templates?

AI medical scribes streamline the note-taking process by transcribing patient interactions in real-time. This reduces errors and ensures consistency, unlike paper-based templates which are more time-consuming and prone to missing details. 

What does an ADIME note template look like in Heidi?

Our AI-enabled ADIME note templates are automatically structured, with clearly labeled sections for Assessment, Diagnosis, Intervention, and Monitoring and Evaluation. Copy this Google doc to view our free sample ADIME note template.