ADIME
ADIME is a 4-step documentation process that is frequently used in healthcare settings (most commonly with clinical dietitians) as a way of standardize charting (entering information into patient health records) that provides for consistency among the various disciplines. It helps with organizing your assessment into a concise and organized manner.
It is an acronym that stands for:
- Assessment – Gathering considerable amount of subjective and objective data
- Diagnosis – Develop a diagnosis from the data and information gathered (if applicable)
- Intervention – Determining what you want to see achieved (goals) through the interventions
- Monitoring and Evaluation – How often will you be checking up on the effectiveness of the interventions, and how often will you be checking up on what you are monitoring.
The following example is given for a long-term care patient:
- (Assessment) Patient has had 5% body weight loss in 30 days, resulting in BMI 21.5, indicating below desirable weight range (based on BMI 23.0-29.9). Current body weight is 60.5 kg, usual body weight is 64.0 kg. Patient reports decreased interest in food related to difficulty swallowing. Registered Dietician (RD) performed meal time observation and noted increased coughing after eating, and clearing their throat frequently. No noted issues with liquids. RD suspects weight loss is related to decreased intake secondary to Dysphagia. See assessment section of the chart for RD’s full nutrition assessment and findings.
- (Diagnosis) Swallowing difficulty related to Dysphagia as evidenced by frequent throat clearing, coughing, and patient reports.
- (Intervention) RD has consulted the Speech-Language Pathologist (SLP) for a swallowing assessment to be completed within 2 days. RD has changed diet to minced texture after discussion with patient and SLP. Patient is agreeable to temporary change until SLP assessment. RD will also introduce 2Cal TID 60 mL with Medpass.
- (Monitoring) RD will perform a second meal observation to assess how minced texture diet is being accepted and tolerance. RD will also assess SLP’s assessment when completed. RD will also monitor patient’s weight.
- (Evaluation) RD will evaluate meal observation results and make changes as needed. RD will follow-up after SLP assessment is complete. RD will assess patient’s weight weekly for 4 weeks.
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