Example ADIME Intake Note

Example ADIME intake note Patient Code Number: mmdd(patient initials)(time)(PNC first name) 0915sh1230devon ICD 10 Code: Z71.3 Dietary Counseling and surveillance Site of Visit: HP Date patient was seen: 9/15/16 Complaint/Reason patient stated for visit: Weight management and general healthy eating Pt. Visit: New Patient ASSESSMENT: Food intake: In this box, comment on things that patient has talked about related to client’s food intake (e.g. common foods eaten, when, food preferences, dislikes, etc.) Patient eats a small breakfast, usually a protein bar or cereal; 3-4 later: lunch, her biggest meal. Includes variety of things (Geronimo’s dining hall) E.g. salad, light dressing, ~2 chicken wings, flavored beverage (iced tea or cappuccino), chips or other snacks. Dinner: usually cereal with 2% milk and fruit or something frozen she can microwave. Sometimes has a bowl of kettle corn or a couple cookies after dinner. Food Allergies/Intolerances: None noted Pertinent Meds, include complementary/alternative medicine use: Daily multiple vitamin, Lipitor [Chol] Knowledge/beliefs, food and supplies availability: Easy access, mother prepares foods at home. The patient states that she does not have much nutrition knowledge, however is aware she needs to change her habits and is ready/willing to try. Physical activity/exercise: Parks far away and walks to and from class from dorms MW; tries to walk TR for 30 minutes. Anthropometric measurements: Patient age: 18 yo Gender: Female Date of birth: 2/17/1998 Height: 5 ft. 6 in. 167.64 cm Weight: 160 lbs. 72.67 kg Weight History: 30-pound weight gain in last 6 months; previously, normal wt. UBW: IBW: BMI: 25.8 [Overweight] BF: Pt Wt Goal: 145 lbs Biochemical Data (e.g., electrolytes, glucose), Medical Tests, & Procedures (only if lab work is provided) E.g. GLUC: 115; Total Cholesterol: 214; LDL: 123 Example ADIME intake note Nutrition-Focused Physical Findings (physical appearance, muscle and fat wasting, appetite, and affect): Pale skin, no noted muscle definition; no noted problems with appetite Self-Reported Client Hx (Personal hx, medical/health family hx, treatments, including complementary/alternative, & social hx): Family hx of obesity. Patient states, “everyone in my family is overweight or obese”. Expressed concern because of hx. The patient states that she recently had about a 30-pound weight gain in last 6 months. Additional notes: (Include your assessment of the patient’s dietary recall or reporting.) The patient is an 18 yo female with a BMI of 25.8 and is considered to be overweight. The patient seems to have a fairly balanced diet; all food groups are represented. However, the patient does not eat through out the day, rather she eats 3 meals, lunch being particularly large. She consumes a high amount of calories and fat from snack foods, such as chips and cookies. Patient is aware that she needs to change her lifestyle, and is ready and willing to change eating habits to become more fit and manage weight better. Patient would benefit from weekly nutrition counseling visits and monitoring of weight and food intake. Calorie reduction is her main goal with the addition of more fruits and vegetables into her daily diet. DIAGNOSIS [To help here, go to our class website, “NCP Planning”.] Intake Excessive energy intake [calories and fluids] [NI – 1.5] Clinical Increase in BMI [NC 3.3] Behavioral-Environmental May include inability to choose right foods, quantities [NB – 1.1] Which domain does this fall into? Is it Intake, Clinical, or Behavioral? DIAGNOSIS [Continued] (You MUST show your work.) Estimated caloric needs: Based on Mifflin St Jeor Equation: • BMR female: (10 x weight [kg]) + (6.25 x height cm) - (5 x age in years) - 161 E.g. (10 x 73 kg) + (6.25 x 167 cm) – (5 x 18 yrs) - 161 (730) + (1044) – (90) - 161= 1523 calories • TEE: 1523 BMR x 1.2 Activity Factor [sedentary] = 1828 calories [I used 1.2 as activity factor because of her description of exercise] • [to adjust for weight change goal: -250 calories = 1578 calories [The formula for a the BMR male is: (10 x weight [kg]) + (6.25 x height cm) - (5 x age in years) + 5] Example ADIME intake note DIAGNOSIS [Continued] PES [Can use any of the 3 problem categories, but here used NB. Problem: Excessive caloric intake as related to Etiology: lack of knowledge of healthier choices, serving sizes as evidenced by Signs/Symptoms: BMI, self-reported gain in <6 months; description of intake. Patient is in what stage of change? Preparation INTERVENTION [AKA Plan) Patient agrees to try to: (These must be measurable) ü Add a snack between breakfast and lunch at least 3 days/week to avoid being overly hungry daily. ü Drink two 12 oz bottles of water per day at least 3 days/week ü Try the MyFitnessPal application to keep track of food intake for 3 consecutive days per week. ü Schedule a follow-up appointment within the next two weeks. Interventions: Estimated calorie needs are 1,828 kcals/day; adjusted to 1,578 kcals/day to obtain negative energy balance. Have patient work with MyFitnessPal or ChooseMyPlate application to monitor food intake. Recommendations: Eat small snacks between meals instead of two to three giant meals a day to ensure calories are equally distributed throughout the day. Implement vegetables into daily routine. Increase water consumption to assist with weight loss and hydration. Would benefit from continued monitoring. Educational material provided: ChooseMyPlate, MyFitnessPal Coordination of Nutrition Care: Continued monitoring by PNC and RDN MONITORING & EVALUATION PNC [RDN] Follow-up plan: Track progress by asking her about her water consumption and checking her food intake on the application. Discuss the level of difficulty to maintain the changes implemented the prior week. Discuss any challenges or things preventing her from achieving the obtainable goals set. Introduce the importance of vegetables in regards to weight loss and discuss some vegetables that she enjoys. Give examples of easy ways to cook/eat vegetables (give some recipes).