Dietitian Template

ADIME

A professional Dietitian template for healthcare professionals.

About this template

The ADIME template is a comprehensive documentation tool used by dietitians to assess, diagnose, intervene, and monitor a patient's nutritional status. This template is ideal for dietitians who need to create detailed nutrition care plans, including dietary assessments, weight management strategies, and lifestyle modifications. It covers a wide range of factors such as anthropometrics, diet patterns, physical activity, and lifestyle influences, ensuring a holistic approach to patient care. The ADIME template is particularly useful for tracking progress and setting SMART goals, making it an essential resource for effective nutrition management.

Preview template

Reason for visit: Patient is seeking guidance on weight management and improving 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 guidance 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

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)]

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