ADIME

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)]