The attached ADIME template needs to be filled out with appropriate information and medical abbreviations. All the correct information is given but experience is needed to fill out the note for the case study information. The budget is not higher because I have all the correct information. I just need a tutor with medical and dietetics experience to fill out the chart note with the correct information.
ADIME Format
Your note
A
Example Delete this row and column when turning in your final note
CH
77 y/o male adm ć stage III decub. Hx of depression on MAOI. Pt
lives alone ć son visiting once per month. Pt c/o poor appetite.
Denies N/V/D/C
Meds: Nardil (phenelzine)
AD
Ht: 5’10” Wt: 145# (Per chart) UBW 153# (1 month) 95% UBW
IBW: 166# + 10% (149-183#) IBW % 97% LL BMI 20.8 ↔
COMMENTS
Use this column as a check to make sure you have
all the data you need.
Delete this column when turning in your final note
Convert to Portrait Layout to turn in
Remove all the lines- home-paragraph tab-no
borders- see final page below
Put new topic on new line ex. anthropometrics,
labs, meds etc.
Clinical Hx:
age/FM/dx/PMH/treatment
Nutr: c/o such as N/V/D/C, I/Os
social hx
Meds: Pertinent meds (do not need dose)
Anthropometric data:
Indicate Wt per RN, per pt, per chart with timing
IBW % ↑/ ↓WNL/ ↔
If pt’s wt is within the range then put WNL or use LL
if pt’s wt is low or UL if above the range
UBW must have timing of wt ∆
BMI: Include normal overwt/obese etc.
Nutrition Focused Physical Findings
Phys appear/muscle/ wasting/dentition
swallow/appetite/NFPE see ASPEN/AND guidelines
Food Hx:
PO Intake kcal/pro/fat/fiber/fluid/
and/or TPN/EN intake (kcals, pro, fluid provided)
Diet hx/env
Diet order (per chart) or MD diet order
Knowledge/belief/attitude/motivation/behavior/PA/
mobility
Access
Food drug interactions
Kcal, pro, and fluid needs (include factors used)
Include ↓↑↔ on all labs
NPF
FH
BD
Pt has poor dentition and unable to chew regular diet especially
meats. Overall thin appearance, sunken orbitals, slight depression of
temples
Diet hx: Pts diet PTA inadequate in Kcals and protein. Pt states he
has been too tired to eat and appetite is poor for 2 weeks. Eating <
50% for 2 weeks. Pt states he has been unable to chew meats so
has been eating cheese. Pt unaware that cheddar cheese
contraindicated with MAOI.
Son visits once per month. Provides some assistance with meals.
Diet order: Regular (date) -MD ordered diet
PO intake 25% of meals per nursing
Potential Food Drug interaction: Pt consumes cheddar cheese while
on Nardil MAOI
Estimated needs: 2300 kcals (35kcals/kg), 86-105g pro (1.3-1.6g/kg);
fluid: 2300ml (1 ml/kcal)
Labs: Glu 90mg/dL↔ , Alb 2.8 mg/dL↓
D
1.
Severe malnutrition related to poor PO intake as evidenced by
physical exam findings consistent with fat and muscle wastingtemporal wasting and sunken orbitals, and 5% wt loss in past month,
and < 50% PO intake > 14 days
2
or. …Inadequate caloric and protein Intake R/T
Increased requirements for wound healing, poor appetite, and poor
dentition AEB 5% Wt loss in 1 month, alb 2.8mg/dL ↓, Stage III
decub, and PO intake < 50% x 1 month
List all appropriate labs for THIS case ć mg/dL Alb,
Glu, HA1C, Chol, HDL/LDL, TG, H/H MCV, K, Na, P,
ABGs, Other
If using malnutrition as dx- see ASPEN/AND
Guidelines
3.
FND
If comparing intake to recommended use a
percentage for clarity for the MD
Potential Food Drug interaction related to knowledge deficit of
contraindicated food and Meds as evidenced by pt’s intake of
cheddar cheese while on Rx Nardil
INTERVENTION
I
PES: Problem related to the Etiology as evidenced by
S&S (measurable Signs and Sx)
Make sure it is a true cause and something that you can
do something about. Preferably the intake domain per
the Academy
YOUR “S” should be able to be “copied” to your M/E- this
will be a way that you can tell if you made a difference
with your intervention.
1.
2.
3.
4.
5.
6.
Recommend diet change to Mechanical Soft diet
Will provide high kcal and protein snack between meals
Provide high protein, high kcal foods per pt preference
No high tyramine foods
Recommend Calorie Count to monitor PO intake
Recommend Commercial beverage (Ensure BID) if no
improvement in PO intake in 2 days
KEY POINT: YOUR INTERVENTIONS ADDRESS YOUR “E” OF
YOUR PES STATEMENTS ABOVE
Do not put an intervention for a problem you have not
identified- go back and make a PES if you need to.
If you listed a problem- you must have an intervention for
it—either FND, NE, CC
USE WHEN:
Pt is in hospital and you want the MD to change the diet in
some way or you plan to adjust the diet in some way that
does not need MD approval.
Meal distribution- what FS dept. will provide while in
hospital
• Provide __________diet (as ordered)
• Recommend Diet order change to _______ (if needed)
• Will provide ↑or ↓protein/kcal/snacks/fiber/fluid/
• Recommend Commercial Beverage (ex. Ensure BID/TID)
if needed
NE
1. Educated pt and son and encouraged high Kcal and pro
meals and snacks
2. Educate pt and son on high tyramine foods to avoid while on
Nardil
USE WHEN:
You have a brief education time - pt is in acute
care/hospital- Pick NE or NC, but not both.
If you think pt should talk to their doc about med changesput it in your med note here
Do not put pt and family if not appropriate for THIS pt.
• Educated pt/family on _________diet
• Educated pt /family on importance of_________
• Encouraged ___________
• Leave details of diet out of medical note ie what
constitutes a high fiber diet.
USE WHEN:
You have ongoing counseling with pt. Usually at least 30
min and outside of hospital setting. Use for outpt
counseling
NC
•
•
CC
Refer to SW for Meals on wheels referral ṕ discharge
Do not refer to the MD already on the case
Do not refer to pharmacy regarding a med if you
can talk to the pt about it.
Nutritional Counseling
Usually reserved for ongoing counseling session –
outpatient. Leave out of not using it.
USE WHEN: You want to make a referral to someone out
of your field such as SW, SLP
•
•
•
•
M/E
1.
Prevent further wt loss
Pt to consume 75% of meals/snacks through hospital stay
Who do you refer to? Areas out of your expertise or
after discharge
Refer to SW for MOW/any discharge
assistance/access
Refer to SLP for swallowing eval
Do not refer to pharmacist for food drug intx- you
take care of it
Look at "S" of PES list values with timing of improvement must be measurable- put a number on it if you can. Includes
wt changes, lab values. Can also include sx resolving or lack
of sx.
MUST BE SOMETHING YOU OR MD WILL BE ABLE TO CHECK
ON. DO NOT PUT PT’s FOOD RECORD WILL SHOW…… for
acute settings. (can use for counseling)
2.
3.
4.
Healing of decub; diarrhea will resolve, No sx of__________
Alb to trend WNL through hospital stay/or by next MD office visit
Pt to discontinue intake of ____(food) while on Rx__________
© Copyright. Samantha Davis, 2023. This work is licensed under a Creative Commons Attribution-Non-Commercial-No Derivatives 4.0 International License.
Your actual ADIME note will be diminished to these areas listed below. Add as many points as needed. Convert to portrait layout to turn in.
A:
D:
1.
2.
3.
I:
FND
NE
NC
CC
M/E:
1.
2.
3.
Assessment Information (Include: hemoglobin, hematocrit, MCV)
IBW = 140# +/-10%
105.7% IBW
2.6% weight loss in one year
hasn’t been formally
diagnosed with anything!!
BMI = 22.6 indicative of healthy weight for height
Est kcal intake = 1735 kcal/day
Est protein intake = 68 g protein/day
Use 26-27 kcal/kg/day to estimate kcal needs; Use 1.1-1.2 g protein/kg/day to estimate
protein needs; Use 35 mL/kg to estimate fluid needs
Mifflin St. Jeor – 1461 kcal/day
MCV = 71.4
MCH = 23.8
MCHC = 33.3 g/dL
Lab values indicate microcytic anemia
Vitamin B12 intake sufficient
Vitamin C intake mildly insufficient
Iron intake insufficient
PES Statements
Inadequate mineral intake of iron related to food and nutrition knowledge deficit re:
vegan diet as evidenced by Hgb =10 g/dL, pallor of face, fatigue, no intake of heme iron
and low intake of non-heme iron per food recall.
Increased iron needs related to increased blood loss secondary to heavy periods and
decreased iron absorption due to high intake of polyphenols
from tea and consuming vegan diet as evidenced by biochemical (Hgb =10 g/dL,
Hct=32%, MCV=71.4 μm3, MCH=23.8 pg, MCHC=33.3%) and clinical evidence of iron
deficiency (pallor and fatigue).
Diagnosis:
1. Inadequate mineral intake of iron related to food and nutrition knowledge deficit
re: vegan diet as evidenced by Hgb =10 g/dL, pallor of face, fatigue, no intake of
heme iron and low intake of
non-heme iron per food recall.
2. Increased iron needs related to increased blood loss secondary to heavy periods
and decreased iron absorption due to high intake of polyphenols
from tea and consuming vegan diet as evidenced by biochemical (Hgb =10 g/dL,
Hct=32%, MCV=71.4 μm3, MCH=23.8 pg, MCHC=33.3%) and clinical evidence
of iron deficiency (pallor and fatigue).
Intervention:
● Nutrition Education re: iron rich food options appropriate in vegan diet, increased
iron needs of 1.8 times non-vegan diet for those following vegan diet, role of
foods/beverages that impact absorption (vitamin C, tannins, and phytates), iron
supplement information and timing of iron intake through foods/supplements, and
management of possible constipation (increased fluid/fiber/activity) resulting from
iron supplementation. Discussed other potential nutrients of concern with vegan
diet (Vitamin B12, Calcium, Vitamin D, Zinc, Omega 3 fatty acids) and food
sources.
● Coordination and Referral of Nutrition Care with physician to provide therapeutic
Fe Rx and follow-up appointment to monitor status of laboratory values
● Coordination and Referral of Care: Pt to follow-up with either PCP or
gynecologist to address heavy menstrual periods.
Goals:
● Pt will consume at least four servings of iron rich foods daily combined at the
same time with one serving of vitamin C rich food/beverage (both from provided
list) as logged in food diary for next month.
● Pt will decrease coffee and tea intake to a total of < two 8 oz cups of coffee daily
within two weeks per food diary.
● Pt will take 45 mg of over the counter ferrous sulfate or ferrous gluconate with ½
cup orange juice and on an empty stomach daily until a prescription for higher
dose iron is obtained.
Monitoring and Evaluation
1. Pt to maintain a food diary and bring to f/u appointment in one month. RD will
review/monitor food intake including Vitamin C and iron containing foods and total
caffeine intake (tea/coffee) at that time.
2. Review overall iron intake from dietary supplement/iron Rx and foods (per food diary).
3. Monitor Nutrition Anemia Profile (Hbg, Hct, MCV, TIBC, Serum Ferritin, Serum Iron,
TSAT). Recommend labs run ~ 5-7 days before appointment.
Objectives:
• Use current information technologies to locate and apply evidence-based guidelines and protocols, such as
the Evidence Analysis Library.
• Describe the governance of nutrition and dietetics practice, such as the Scope of Practice for the Registered
Dietitian Nutritionist and the Code of Ethics for the Profession of Nutrition and Dietetics. (KRDN 2.2)
• Utilize the Nutrition Care Process.
• Demonstrate documentation that follows professional guidelines.
Ms. Espinoza is a 26 YO Hispanic female. She is a graduate student at TCU and works as a graduate assistant in the
English Department. She presented to the Student Health Center after feeling weak and lethargic for the past few
months. Prior to the visit, patient reports fatigue for the past two or more months and worsening in the last two
weeks.
Ms. Espinoza is a vegan and has been for about one year. Her weight has been stable for the past year. Prior to
that time, her weight was approximately 152#. She initially chose a vegan lifestyle for environmental and animal
rights purposes. She has become more committed to the lifestyle for health reasons over the past two years. She
reports that her appetite is fine. She does not consume any meat, poultry, fish, milk or eggs. She consumes
legumes regularly, drinks plain soy milk, and eats soybeans and tofu regularly. She usually consumes legumes
meals and also tries to eat a whole grain at the same time. She does not take any medications or dietary
supplements. She has no food allergies or intolerances. She reports heavy menstrual periods.
Medical Hx: menarche age 14
Social Hx: Lives in an off-campus apartment alone; Denies tobacco or illicit drug use; Does not consume alcohol or
drugs; Sedentary lifestyle with infrequent exercise. She walks about one mile (round trip) from her off-campus
apartment to campus on weekdays. She takes the stairs to her four-story office on campus and her two-story
apartment off-campus. Otherwise, she rarely exercises.
Symptoms: Dizziness, Pallor, Pale gums, Fatigue, Easily fatigued upon physical activity
Medications/Supplement: none
Ht: 5’8”. Wt: 148#.
Patient’s lab values are as follows:
Test
Glucose
BUN
Cr
Ca
Serum Albumin
RBC
Result
85 mg/dL
12 mg/dL
0.7 mg/dL
8.8 mg/dL
3.7 g/dL
4.2
Reference Value
70-110 mg/dL
10-20 mg/dL
0.5-1.1 mg/dL
9.0-10.5 mg/dL
3.5-5.0 g/dL
4.2-5.4
WBC
76000/mm3
5000-10000/mm3
Test
Na
K
Cl
Hgb
Hct
Platelets
Result
142 mEq/L
4.0 mEq/L
102 mEq/L
10.0 g/dl
30%
270,000/mm3
Reference Value
136-145 mEq/L
3.5-5.0 mEq/L
98-106 mEq/L
12-16 g/dl
37%-47%
150.000400,000/mm3
You are an outpatient RD consulting at the student health care center. You received a consult to assess the patient
due to her reports of fatigue and to provide nutrition education regarding a general, healthy diet. She says that she
feels tired and finds it necessary to take a nap almost every evening after she leaves work before she begins
studying. She drinks 2-4 cups of black tea daily to try to stay awake and alert. She states that she has struggled
academically this semester and thinks that her fatigue is to blame.
You obtain a 24 hour recall from the patient. She reports that he usually eats alone. She does not take any dietary
supplements. This menu is fairly representative of her usual intake. Besides the beverages listed in her recall, Ms.
Espinoza drinks water throughout the day.
Breakfast:
2 6 oz cups of black tea
½ cup raw oats
1 T peanut butter
1 cup Silk Original Soymilk*
½ cup blueberries
1 T pumpkin seeds
Lunch:
3 cups of baby spinach
½ cup canned Kroger salted garbanzo beans
1 cup raw broccoli florets
8 Mezzetta pitted Greek Kalmata olives*
20 Wheat Thins* (crackers)
1 8 oz cup black tea
Snack:
½ large banana
1 oz Kroger dry roasted peanuts*
2 6 oz cups of black tea
Dinner:
Tofu tacos (2 Mission corn tortillas*, 3 oz Trader Joe’s Firm Tofu* cooked in 2 tsp olive oil)
2 tsp soy sauce
½ cup canned salted black beans
1 cup butter lettuce
4 Tablespoons of avocado
water
Snack:
1 cup Silk Original Soymilk*
¼ cup blueberries
water
* find precise information for these items rather than using estimates on the exchange list in your Nelms textbook.
Documentation
Medical Record
• Systematic recording of a patient’s care
• Location where all data related to medical problem is
collected
• LEGAL document
Need to be thorough on documentation to validate and record all things done with patient
Everything is under HIPPA in the file (can bounce ideas
Purposes
• Legal documentation of medical
care that the client has received.
• Document communication
between members of the health
care team.
• Determine patient care
• Evaluation of medical care for
that client.
• Funding & resource
management.
• Continuous quality improvement.
• Third party reimbursement.
• Accreditation.
• Monitor, evaluate and improve pt
care.
• Research.
• Broader picture helps evaluate what needs to happen
• Determines for staffing and funding
Terms
• Current Procedural Terminology
(CPT codes)
– Numeric codes used to describe a
medical service; these codes were
developed by the American Medical
Association with the Health Care
Financing Administration
• Medicare bad reimbursement rates
• Prospective Payment System:
– System developed by the US
government to reimburse health
care providers for inpatient health
services at a predetermined rate for
a particular diagnosis and level of
care
How is the information documented?
Using standard language & medical abbreviations
https://www.tabers.com/tabersonline/view/Taber
s-Dictionary/767492/all/Medical_Abbreviations
• Use standardized terms
Unacceptable abbreviations
https://www.jointcommission.org/facts_about_do_not_use_list/
• U (unit)
• IU (International unit)
• QD, qd (daily)
• QOD, qod (every other day)
• Trailing zero (2.0 mg)
• Lack of leading zero (.3 mg)
• MS, MSO4, MgSO4
Written Abbreviation Notes
• No @; write out at; can be mistaken for the number 2.
• No > or
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