ADIME Notes for Medical Nutrition Therapy

Resident Name: [Enter Resident Name] (only include if explicitly mentioned in the consultation or clinical documentation) Date: [Enter Date] (only include if explicitly mentioned) Time: [Enter Time] (only include if explicitly mentioned) RD Name: [Enter RD Name] (only include if explicitly mentioned, include credentials if provided) (A) Assessment: Age: [Enter Age] (only include if explicitly mentioned) Gender: [Enter Gender] (only include if explicitly mentioned) Weight: [Enter Weight] (only include if explicitly measured or recorded during the consultation) Height: [Enter Height] (only include if explicitly measured or recorded) Body Mass Index (BMI): [Enter BMI] (only include if explicitly calculated or recorded) Usual Body Weight (UBW): [Enter UBW] (only include if mentioned or available) Weight History: [Enter weight trends over 30, 90, and 180 days if available] (include date-specific weight points and note weight changes) IBW/%IBW: [Enter Ideal Body Weight and % of IBW] (only include if explicitly mentioned or calculated) Appetite: [Enter description of appetite status] (only include if appetite details were reported or observed) Food Allergies/Intolerance: [Enter any known food allergies or intolerances] (only include if documented or stated by the resident) Food Preferences: [Enter food preferences] (only include if discussed or documented) Adaptive Devices: [Enter any adaptive devices used for eating] (only include if mentioned) Current diet order: [Enter diet order] (only include if explicitly stated or documented) % intake of meals: [Enter percentage intake] (only include if explicitly recorded or estimated) Supplement order: [Enter type and amount of supplements] (only include if prescribed) % intake of supplement: [Enter supplement intake percentage] (only include if known or observed) Chewing or swallowing difficulty: [Describe any difficulties] (only include if applicable) Feeding Assistance: [Enter level of assistance required for feeding] (only include if explicitly mentioned) Skin condition: [Describe current skin status] (only include if documented) Medical diagnosis: [List relevant medical diagnoses] (only include if explicitly mentioned in the clinical records) Pertinent labs: [Enter any relevant lab values] (only include if related to nutrition assessment or status) Pertinent medications: [Enter medications affecting nutritional status] (only include if relevant) Nutritional Focused Physical Exam (NFPE): Appearance: [Describe physical appearance findings] (only include if assessed) Body Fat: [Describe findings related to body fat stores] (only include if assessed) Orbital: [Select one: Mild / Moderate / Severe / Unable to assess] (only include if assessed) Triceps: [Select one: Mild / Moderate / Severe / Unable to assess] (only include if assessed) Fat overlying ribs: [Select one: Mild / Moderate / Severe / Unable to assess] (only include if assessed) Muscle Mass: Temple: [Select one: Mild / Moderate / Severe / Unable to assess] Pectoralis: [Select one: Mild / Moderate / Severe / Unable to assess] Delt: [Select one: Mild / Moderate / Severe / Unable to assess] Hand: [Select one: Mild / Moderate / Severe / Unable to assess] Back: [Select one: Mild / Moderate / Severe / Unable to assess] Thigh: [Select one: Mild / Moderate / Severe / Unable to assess] Hydration Status: [Enter hydration assessment] (only include if assessed) Malnutrition Status: [Describe level and evidence of malnutrition, referencing MNA or other tools if used] (only include if malnutrition is diagnosed or suspected) Daily Estimated Nutrition Needs: Per [Enter weight or method used] Total calories (kcal): [Enter caloric estimate] (include method used to estimate) Total protein (g/kg): [Enter protein needs] (include method used to estimate) Total fluids (ml): [Enter fluid requirements] (include method used to estimate) Does current meal and supplement intake meet estimated needs? [Select one: Yes / No] (only include if evaluated) (D) Nutrition Diagnosis: [Enter specific nutrition diagnoses] (describe using standardised language such as PES statements. Include underlying cause and signs/symptoms if available) Nutrition goals (SMART): [Enter nutrition goals using SMART criteria] (include measurable targets for weight, intake, or other clinical outcomes) [Indicate whether care plan has been updated to reflect current nutrition goals] (I) Nutrition Interventions/Recommendations: [Describe nutrition interventions and recommendations] (include any dietary modifications, changes to supplement orders, referrals, and educational points. Use full sentences or brief bullet points as structured in the original note) [Indicate whether RD interventions and recommendations were communicated to Nursing staff and Physician] [Indicate whether care plan has been updated to reflect current RD interventions and recommendation] (M/E) Monitoring and Evaluation Plan: [Enter monitoring and evaluation strategy] (include what will be tracked, how frequently, and intended outcomes; e.g. weight, intake, labs, and follow-up plans) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)