ADIME Note Template for Registered Dietitians

What This Template Is For

The ADIME format (Assessment, Diagnosis, Intervention, Monitoring and Evaluation) is the documentation standard recommended by the Academy of Nutrition and Dietetics for registered dietitians. It maps directly to the Nutrition Care Process (NCP) and is the structure most payers and supervisors expect to see.

This template gives you a copy-paste starting point for outpatient nutrition counseling visits. After the blank template, you will find a complete fictional example for an initial visit with a type 2 diabetes patient, followed by a follow-up example. At the end, a pre-sign checklist covers the most common errors that create audit risk or claim denials.

If you want the full rationale behind each section, including how ADIME differs from SOAP, what labs belong in which section, and setting-specific adjustments for hospital, telehealth, and private practice, see the companion guide: How to Write ADIME Notes: A Complete Guide for Registered Dietitians.

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ADIME vs. SOAP: The Core Difference

SOAP was designed for medical encounters. The Assessment component is where a physician forms a differential diagnosis and reaches a clinical conclusion. In SOAP, Assessment answers the question: "What is wrong with this patient?"

ADIME's Assessment component is something different. It is a structured data-collection section covering anthropometric, biochemical, clinical, dietary intake, and environmental data. It is where you show what you found, not what you concluded. The conclusion belongs in the Diagnosis section.

This matters in practice because dietitians who document in SOAP often collapse the actual nutrition diagnosis into the Plan or omit it entirely. The result is a note that describes a conversation without ever clearly naming the nutrition problem being addressed. ADIME forces that specificity.

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The Blank Template

A: Assessment

Anthropometric data:

• Height: [ft/in or cm]
• Current weight: [lb or kg] | Date: [date]
• Usual body weight (UBW): [lb or kg]
• BMI: [calculated]
• % Weight change: [%] over [time period] (unintentional / intentional / unclear)
• Other: [waist circumference, body composition if assessed]

Biochemical data (relevant labs):

• [Lab name]: [value] ([reference range]) — [date]
• [Lab name]: [value] ([reference range]) — [date]
• [Note any trends if repeat labs available]

Clinical data:

• Primary diagnosis: [ICD-10 code and description]
• Relevant comorbidities: [list]
• Relevant surgical history: [list or N/A]
• GI function: [normal / altered; describe if altered]
• Current medications with nutrition implications: [list or none]
• Relevant physical findings: [muscle wasting, edema, dentition, swallowing if assessed]

Dietary intake data:

• Assessment method: [24-hour recall / food frequency questionnaire / diet history / other]
• Estimated energy intake: [kcal/day]
• Estimated protein intake: [g/day]
• Estimated carbohydrate intake: [g/day]
• Estimated fat intake: [g/day]
• Appetite: [good / fair / poor] | Changes: [describe]
• Eating pattern: [meals per day, timing, skipped meals, snacking patterns]
• Fluids: [estimated oz or mL per day; types]
• Key dietary findings: [notable patterns, excesses, deficiencies]

Environmental and client history:

• Living situation: [lives alone / with family / other]
• Food access: [grocery access, food insecurity screening result if conducted]
• Cooking ability and responsibility: [who prepares meals, equipment available]
• Cultural or religious food practices: [if relevant]
• Work / schedule factors: [shift work, travel, eating on the go]
• Physical activity: [type, frequency, duration]
• Readiness to change: [pre-contemplation / contemplation / preparation / action / maintenance]
• Psychosocial factors: [relevant stressors, history of disordered eating, food beliefs]

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D: Diagnosis

Nutrition diagnosis (PES statement format):

[Nutrition diagnosis term using Academy terminology] related to [etiology] as evidenced by [measurable signs and symptoms].

For initial visits with multiple problems, document up to 2-3 diagnoses in priority order. At follow-up, reassess each diagnosis and update based on clinical findings.

Primary diagnosis: [PES statement 1]

Secondary diagnosis (if applicable): [PES statement 2]

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I: Intervention

Goals for this patient (collaborative, patient-centered):

1. [Short-term goal tied to etiology of primary diagnosis]
2. [Short-term goal tied to secondary diagnosis if present]
3. [Long-term goal]

Nutrition prescription:

• Energy target: [kcal/day] based on [calculation method: Mifflin-St Jeor, Harris-Benedict, estimated, other]
• Protein target: [g/day or g/kg]
• Carbohydrate target: [g/day or % of calories] | Distribution: [if relevant]
• Fat: [target or qualitative guidance]
• Fluid: [target if applicable]
• Other: [fiber, sodium, potassium, other specific nutrient targets]

Education and counseling provided this session:

• Topic 1: [specific topic name, not just "nutrition education"]
• Materials provided: [handout name / none]
• Patient response to education: [describe understanding, questions asked, stated concerns]
• Topic 2 (if applicable): [topic, materials, response]

Behavior change strategies used:

• [Motivational interviewing / goal-setting / cognitive restructuring / problem-solving / other]
• Specific strategy applied: [describe briefly]

Coordination and referrals:

• Communicated with: [physician, diabetes educator, social worker, other] regarding [topic]
• Referrals made: [to whom, for what]
• Referrals received: [from whom, reason]

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M/E: Monitoring and Evaluation

Parameters to monitor at next visit:

Outcomes to evaluate:

• Nutrition diagnosis resolution criteria: [what measurable evidence will indicate PES statement is resolved]
• Patient-reported outcomes: [how will you assess behavior change, self-efficacy, quality of life]

Plan for next visit:

• Next session date: [date or interval]
• Anticipated session length: [30 min / 60 min]
• Topics planned: [what to address next session]

Billing information:

• CPT code: [97802 = initial / 97803 = follow-up / 97804 = group]
• Minutes of face-to-face time: [document for time-based codes]
• Qualifying diagnosis confirming MNT medical necessity: [ICD-10]
• Insurance authorization remaining units: [if applicable]

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Fictional Example: Initial Visit, Type 2 Diabetes (Outpatient)

Patient: Rosa M., 54-year-old woman referred for MNT by her primary care physician following new diagnosis of type 2 diabetes mellitus (E11.9). All names and clinical details are fictional.

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A: Assessment

Anthropometric data:

• Height: 5'4" (162.6 cm)
• Current weight: 194 lb (88 kg) | Date: 2026-04-09
• Usual body weight: 197 lb over the past year
• BMI: 33.3 kg/m2 (class I obesity)
• % Weight change: -1.5% over past 12 months (no intentional effort)

Biochemical data:

• HbA1c: 8.7% (target below 7.0%), 2026-03-28
• Fasting glucose: 162 mg/dL (reference: 70-99 mg/dL) — 2026-03-28
• Total cholesterol: 214 mg/dL — 2026-03-28
• LDL: 138 mg/dL (target below 100 mg/dL for T2DM per ADA), 2026-03-28
• HDL: 44 mg/dL — 2026-03-28
• Triglycerides: 198 mg/dL — 2026-03-28
• eGFR: 71 mL/min (no current CKD; monitor annually) — 2026-03-28

Clinical data:

• Primary diagnosis: Type 2 diabetes mellitus (E11.9)
• Comorbidities: Hypertension (I10), hyperlipidemia (E78.5), class I obesity (E66.01)
• GI function: Normal. No reported nausea, dysphagia, or altered bowel habits.
• Current medications: Metformin 500 mg twice daily (started 6 weeks ago); lisinopril 10 mg daily; atorvastatin 20 mg daily
• Physical findings: No peripheral edema. No signs of muscle wasting. Normal dentition.

Dietary intake data:

• Assessment method: Multiple-pass 24-hour recall (previous day, weekday)
• Estimated energy intake: 2,050 kcal
• Estimated protein intake: 68 g
• Estimated carbohydrate intake: 290 g (57% of calories)
• Estimated fat intake: 72 g
• Appetite: Good, no changes
• Eating pattern: Typically skips breakfast, large lunch (often at work cafeteria), moderate dinner, frequent evening snacking (crackers, fruit juice, packaged cookies)
• Fluids: Approximately 24 oz water, 16 oz orange juice (morning), 12 oz sweetened iced tea at lunch
• Key findings: High glycemic load from juice and sweetened beverages, large carbohydrate bolus at evening snack, minimal dietary fiber, low protein relative to body weight

Environmental and client history:

• Living situation: Lives with husband; two adult children not at home
• Food access: No food insecurity. Grocery access good. Eats out 3-4 times per week.
• Cooking: Husband cooks most dinners; Rosa handles weekend cooking. Has basic kitchen equipment.
• Cultural practices: Mexican-American background; diet includes tortillas, rice, beans, tamales for family gatherings. No dietary restrictions.
• Work schedule: Works full-time as a school administrator; lunch is typically rushed.
• Physical activity: Walks 15-20 minutes, 2-3 times per week. No structured exercise.
• Readiness to change: Contemplation to preparation stage. Reports she is "worried about the diagnosis" and "ready to do something but not sure where to start."
• Psychosocial: No history of disordered eating. Reports stress eating in the evenings related to work demands.

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D: Diagnosis

Primary diagnosis: Excessive carbohydrate intake related to limited knowledge of carbohydrate sources and portion sizes, and habitual consumption of sugar-sweetened beverages, as evidenced by 24-hour recall showing estimated 290 g carbohydrate per day (including 64 g from beverages alone) and HbA1c of 8.7%.

Secondary diagnosis: Food- and nutrition-related knowledge deficit related to new diagnosis of type 2 diabetes and no prior nutrition counseling, as evidenced by patient's inability to identify carbohydrate-containing foods across beverage, grain, and snack categories, and patient's self-report of uncertainty about dietary changes needed.

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I: Intervention

Goals (co-developed with Rosa):

1. Eliminate sugar-sweetened beverages within 2 weeks (replace orange juice and sweetened tea with water, unsweetened beverages, or small portions of whole fruit)
2. Add a protein-containing breakfast at least 4 of 7 days within 4 weeks
3. Long-term: Reduce carbohydrate intake toward 160-180 g/day, distributed across 3 meals with no single meal exceeding 60-75 g carbohydrate

Nutrition prescription:

• Energy: 1,800-1,900 kcal/day (based on Mifflin-St Jeor estimated RMR of 1,619 kcal adjusted for activity; moderate deficit to support gradual weight loss of 0.5-1 lb/week)
• Protein: 75-88 g/day (1.0-1.1 g/kg current weight; support satiety and lean mass)
• Carbohydrate: 160-180 g/day distributed across meals; prioritize low-glycemic sources, limit refined grains and added sugars
• Fat: Moderate; emphasize unsaturated sources; limit saturated fat given elevated LDL
• Fiber: Target 25-30 g/day (currently estimated at 10-12 g)
• Sodium: Moderate restriction given hypertension; target below 2,300 mg/day

Education and counseling:

• Topic 1: Sugar-sweetened beverage sources and impact on blood glucose. Reviewed the carbohydrate content of orange juice (26 g per 8 oz), sweetened iced tea (22 g per 12 oz), and packaged snacks. Rosa expressed surprise at the juice content ("I thought juice was healthy"). Provided handout: "Beverages and Blood Sugar."
• Topic 2: Plate method for meal planning. Introduced the Diabetes Plate as a visual framework for building balanced meals without counting grams. Rosa identified realistic application at the work cafeteria. Provided handout: "The Diabetes Plate."
• Patient response: Engaged, asked specific questions about coffee creamer and tortillas. Agreed to swap juice for whole fruit this week as first step.

Behavior change strategies:

• Motivational interviewing: Explored ambivalence around evening snacking (identifies it as stress relief). Elicited patient's own reasons for change ("I don't want to be on insulin").
• Goal-setting: Collaboratively set the beverage swap goal as a single, concrete, achievable first step rather than overhauling the entire diet.

Coordination:

• Note sent to referring physician (Dr. Fernández) summarizing nutrition diagnosis, goals, and carbohydrate targets. Requested repeat HbA1c at 3 months.

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M/E: Monitoring and Evaluation

Resolution criteria for primary diagnosis: Dietary recall at follow-up showing carbohydrate intake within 160-180 g/day target and elimination of sugar-sweetened beverages, with declining HbA1c trend over 3-6 months.

Plan for next visit:

• Date: 4 weeks (approximately 2026-05-07)
• Anticipated length: 30-minute follow-up (CPT 97803)
• Topics: Review beverage swap progress; introduce carbohydrate counting for grain and snack portions; discuss breakfast options that fit her schedule; address tortilla and rice within cultural food preferences

Billing:

• CPT 97802 (initial MNT, individual, 60 minutes)
• Qualifying diagnosis: E11.9 (type 2 diabetes mellitus)
• Face-to-face time: 62 minutes
• Insurance: Authorization on file; 3 of 3 initial-visit units used

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Fictional Example: Follow-Up Visit (4 Weeks Later)

Assessment:

• Weight: 191 lb (down 3 lb since initial visit)
• Patient reports eliminating orange juice and sweetened tea; now drinking water and one cup of black coffee daily. One relapse during a family event (tamale dinner with juice).
• 24-hour recall (yesterday, weekend): Estimated 210 g carbohydrate. Improved from 290 g but still above target. Breakfast now included 3 of 7 days.
• No new labs since initial visit; repeat HbA1c ordered for 2026-06.
• Reports feeling less hungry in the mornings when she eats breakfast.

Diagnosis:

• Primary diagnosis updated: Excessive carbohydrate intake related to large carbohydrate portions at dinner and weekend family meals, as evidenced by 24-hour recall showing 210 g carbohydrate per day (improved from 290 g baseline) with HbA1c pending.
• Secondary diagnosis resolved: Rosa can now correctly identify carbohydrate-containing foods across all major categories and explain portion effects on blood glucose. Resolved.

Intervention:

• Reviewed progress: Acknowledged beverage change as a meaningful, sustained improvement.
• Education: Introduced carbohydrate counting for grain portions (rice, tortillas, bread). Rosa identified a realistic portion target for tortillas (1 small corn tortilla per meal = 12-15 g) that feels culturally acceptable. Provided handout: "Carbohydrates in Latino Foods."
• New goal: Bring dinner carbohydrate to 45-60 g by focusing on grain portions. Rosa chose to start with reducing rice portion at dinner this week.
• Motivational interviewing: Discussed the family tamale event as a learning moment rather than a failure. Problem-solved strategies for navigating family gatherings going forward.

Monitoring and Evaluation:

• Weight: -3 lb, on trajectory
• Sugar-sweetened beverage goal: Met and sustained
• Carbohydrate intake: Improved but not yet at target; primary diagnosis active, etiology shifting from beverages to grain portions

Plan for next visit: 4 weeks. Topics: Review grain portion progress; introduce label reading for packaged snacks; begin discussion of physical activity increase when Rosa indicates readiness.

Billing: CPT 97803 (follow-up MNT, individual, 30 minutes). Qualifying diagnosis: E11.9. Face-to-face time: 32 minutes.

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Common Documentation Mistakes RDs Make in ADIME Notes

Skipping the PES statement or making it vague. "Patient has poor diabetes control" is not a nutrition diagnosis. It lacks the three-part structure that demonstrates you identified a nutrition-specific problem within your scope of practice and have a clinical rationale for addressing it.

Assessment data without a clear source. Write down how you collected dietary data. "Patient reports" or "24-hour recall" identifies the method. A lab value without a date is not auditable.

Intervention that lists topics without documenting patient response. "Educated on carbohydrate counting" meets the minimum. "Patient correctly identified the carbohydrate content of 4/5 foods listed on label exercise; required additional review of the tortilla and rice examples" tells a supervisor or a payer what actually happened in the session.

Goals that are not connected to the PES etiology. The intervention should directly address the etiology named in the Diagnosis. If the etiology is limited knowledge of carbohydrate sources, the intervention should include education on that specific topic, not a general meal-plan handout.

Monitoring and Evaluation section that is either empty or generic. "Will monitor at next visit" is not a Monitoring and Evaluation plan. Name the specific parameter, the baseline value, the target, and the frequency. This section is the evidence trail that justifies continued treatment.

Omitting billing information or noting incorrect minutes. CPT 97802 and 97803 are time-based codes. The note must document the minutes of face-to-face time. Document this explicitly, not by implication.

Using SOAP-style language in the Assessment. In SOAP, the Assessment is your clinical conclusion. In ADIME, it is your data. If your Assessment section starts with "Patient has poorly controlled diabetes," you are writing a SOAP Assessment, not an ADIME Assessment. Save the clinical conclusion for the Diagnosis.

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ADIME Note Pre-Sign Checklist

Use this before signing any ADIME note.

Assessment

• Anthropometric data includes current weight, height, BMI, and percent weight change with a date
• Biochemical data includes relevant labs with values, reference ranges, and dates
• Clinical data covers primary diagnosis, relevant comorbidities, GI function, and medications with nutrition implications
• Dietary intake section names the assessment method and documents estimated intake with key findings
• Environmental history captures food access, cooking situation, cultural factors, and readiness to change

Diagnosis

• At least one nutrition diagnosis stated using Academy-approved terminology
• Each diagnosis written as a complete PES statement (Problem, Etiology, Signs and Symptoms)
• PES statement is specific and tied to measurable evidence from the Assessment section
• Diagnosis reflects a nutrition-specific problem within RD scope of practice (not a medical diagnosis reworded)
• For follow-up visits: prior diagnoses reassessed and status updated (active / resolved / modified)

Intervention

• Goals are specific and co-developed with the patient
• Goals address the etiology named in the Diagnosis section
• Nutrition prescription documented with specific targets (calories, macronutrients, other relevant parameters)
• Education topics named specifically (not "nutrition education")
• Patient's response to education documented
• Behavior change strategies identified where used
• Coordination with other providers documented if applicable

Monitoring and Evaluation

• Specific parameters listed with baseline values, targets, and monitoring frequency
• Resolution criteria for each active nutrition diagnosis stated
• Plan for next visit includes date/interval, session length, and topics
• Billing information complete: CPT code, qualifying diagnosis, face-to-face minutes, authorization units if applicable

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Streamlining Your Dietitian Notes

If you write ADIME notes across a high volume of patients with similar presentations, nutrition diagnoses tend to cluster. The PES structure for type 2 diabetes patients looks different from the PES structure for renal diet patients, but within each population the patterns repeat. Building reusable templates for your most common case types, with placeholders for the data that changes each visit, can cut documentation time substantially without compromising the clinical specificity that protects your billing. NotuDocs lets you build and fill ADIME templates using your own clinical language rather than starting from a blank note each session.

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Related Articles

• How to Write ADIME Notes: A Complete Guide for Registered Dietitians
• How to Document Dietitian Consultations and ADIME Notes Across Settings
• Medical SOAP Note Template
• How to Document Behavioral Health Screenings in Primary Care