SDSU Medical Nutrition Therapy ADIME Case Study

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ADIME Template
Dietitian Visit
Met with patient
Reason for referral:
NUTRITION ASSESSMENT
Diagnoses and pertinent medical history:
Nutrition order:
Medications
Labs
Weight/
Height/
BMI/
IBW/
Comments: (weight history here)
UBW/
Nutrition-Focused Physical Assessment significant for
Food- and Nutrition-Related Information (24 hour recall):
Nutrition Impact Symptoms: weight loss nausea vomiting constipation diarrhea anorexia
dysgeusia ageusia swallowing difficulties chewing difficulties food allergies/intolerances
Nutrition Needs
Calories
Protein
Fluids
Current intake may meet about % of the energy and protein needs.
Nutrition Subject Global Assessment (Well nourished, moderate or severe malnutrition
Comments: Include 2 criteria to support your assessment
NUTRITION DIAGNOSIS: PES Statements
NUTRITION INTERVENTIONS
Goals
Nutrition Recommendations
Patient Education:
Printed materials provided and reviewed:
Custom list of suggestions provided to implement nutrition goals and recommendations.
Patient verbalizes good understanding and agreement with plan or barriers to the plan.
Contact information for follow-up questions
Coordination of Care:
NUTRITION MONITORING and EVALUATION
Examples: Food records, recall, weights, labs, adequacy of nutrition support, tolerance

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