Dietitian Template

ADIME

A professional Dietitian template for healthcare professionals.

About this template

Looking for a clear and concise way to document your nutritional assessments and interventions? The ADIME note template is a structured format widely used by dietitians to record patient information. This template, when used with Heidi, allows for efficient documentation of assessment findings, diagnosis, interventions, and monitoring plans. It helps dietitians to create comprehensive notes, ensuring all critical aspects of patient care are captured. With Heidi, this template can be quickly populated from your patient visit transcript, saving you time and improving the accuracy of your clinical documentation. This template is perfect for dietitians looking to streamline their note-taking process.

Preview template

Assessment: - The patient, [insert age] Mrs. Evelyn Green, presents with a BMI of 32, indicating obesity. Biochemical data reveals elevated LDL cholesterol (160 mg/dL) and fasting blood glucose (110 mg/dL). She reports a typical dietary intake high in saturated fats and refined carbohydrates. She has no known allergies. - Nutrition-related problems include obesity, hyperlipidemia, and prediabetes. Diagnosis: - Excessive energy intake related to frequent consumption of high-calorie, processed foods, as evidenced by a BMI of 32 and dietary recall. Intervention: - The nutrition intervention plan includes a goal of weight loss of 1-2 pounds per week, improved lipid profiles, and blood glucose control. Expected outcomes are a reduction in BMI, improved LDL cholesterol levels, and fasting blood glucose within the normal range. - Nutrition prescriptions include a 1500-1800 calorie diet per day, with a focus on whole foods, lean proteins, fruits, vegetables, and whole grains. Recommend limiting saturated and trans fats, and added sugars. - Plan for nutrition education and counseling includes providing education on portion sizes, reading food labels, and meal planning. Counseling will focus on behaviour modification techniques to promote adherence to the dietary plan. Monitoring and Evaluation: - Monitor the patient's progress through weekly weight checks, monthly lipid panels, and quarterly HbA1c tests. Criteria for evaluation include a decrease in BMI, a reduction in LDL cholesterol to below 100 mg/dL, and fasting blood glucose below 100 mg/dL. - Follow-up appointments are scheduled for every two weeks for the first month, then monthly thereafter. Reassessment of the dietary plan will occur at each follow-up appointment.

Assessment: - [describe the patient's current nutritional status, including any relevant anthropometric measurements, biochemical data, medical tests, and procedures] (only include the patient's current nutritional status, including any relevant anthropometric measurements, biochemical data, medical tests, and procedures if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [mention any nutrition-related problems or diagnoses] (only include any nutrition-related problems or diagnoses if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Diagnosis: - [state the nutrition diagnosis using standardized language, including the problem, etiology, and signs/symptoms] (only include the nutrition diagnosis using standardized language, including the problem, etiology, and signs/symptoms if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Intervention: - [describe the nutrition intervention plan, including goals and expected outcomes] (only include the nutrition intervention plan, including goals and expected outcomes if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [mention any specific nutrition prescriptions or recommendations] (only include any specific nutrition prescriptions or recommendations if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [outline the plan for nutrition education and counseling] (only include the plan for nutrition education and counseling if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Monitoring and Evaluation: - [describe the plan for monitoring the patient's progress, including specific indicators and criteria for evaluation] (only include the plan for monitoring the patient's progress, including specific indicators and criteria for evaluation if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) - [mention any follow-up appointments or reassessment plans] (only include any follow-up appointments or reassessment plans if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) (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 include 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 on the format, as needed to capture all the relevant information from the transcript.)

Browse more templates

Use this template