adime case study examples

How to Use the Nutrition Care Process (NCP) & ADIME in Practice – Plus Nutrition Care Process Examples!

• February 14, 2023

Written by Olivia Farrow, RD, MHSc

Reviewed by Krista Kolodziejzyk, RD, MPH, MBA

In this article, we break down the steps of the Nutrition Care Process and ADIME charting to help you feel more confident applying them in practice. At the end, you will find Nutrition Care Process examples for 3 practice areas.

Whether you are a new dietitian, a student, or a seasoned dietitian, knowing how to utilize the Nutrition Care Process or ADIME documentation can help maintain consistency and organization in your practice.

This blog post has been developed based on information retrieved from the eNCPT electronic  Nutrition Terminology Reference Manual  2023 edition.

What is the Nutrition Care Process (NCP)?

The Nutrition Care Process (also known as NCP) was developed by the  Academy of Nutrition and Dietetics  and is recognized and used internationally. It was designed to create consistency across the steps of nutrition care, and includes terminology (the Nutrition Care Process Terminology, or NCPT), to keep the language used in documentation standardized. 

The NCP is intended to be used for more than just direct client care. However, for the purpose of this article, we will be focusing on direct client care for the Nutrition Care Process examples provided.

Basically,  the NCP standardizes the steps to take when providing nutrition care to patients/clients.  Following the 4 main steps of the NCP can help provide dietitians with a blueprint for nutrition care. 

The 4 Steps of the Nutrition Care Process

The NCP comprises 4 steps: 

Nutrition Assessment

Nutrition diagnosis, nutrition intervention, nutrition monitoring/evaluation.

Let’s break down what each of these steps includes:

In the assessment stage, relevant information about the client is collected. The information collected will depend on the individual client, the reason you are providing care, and how you are obtaining the information.

For example, a dietitian working in an ICU setting will likely rely more heavily on the patient’s current medical data and the health team to collect information for a nutrition assessment. Whereas a dietitian working in an intuitive eating-focused private practice will collect mostly qualitative data from the client themselves.

How do you know what information to collect in the assessment of a client? 

For the most part, it will depend on your clinical judgment, but the Nutrition Care Process Terminology (NCPT) can help by providing a list of options for assessment data to collect. 

The NCPT for nutrition assessment is combined with monitoring and evaluation, but the main categories relevant for assessment include:

• This includes food and nutrition intake, nutrition supplements, nutrition knowledge and beliefs, food availability, physical activity, quality of life, etc.  
• Height, weight, BMI, weight changes, etc. 
• Labs and tests that are relevant for your nutritional assessment of the client. 
• Physical appearance, swallowing ability, physical signs of nutrient deficiencies, etc. 
• Relevant information obtained about the client’s personal, social, or medical history. 
• Results from assessment tools, such as a validated malnutrition tool. 

Once you’ve collected all relevant information and data, you will compare the data to normal values, nutrient requirements, or what would be considered appropriate for the client’s condition. 

Assessment doesn’t just happen once, but will require reassessment at different stages of the nutrition care relationship. 

At this stage, you will take all that you have learned about the client from your assessment and choose a main nutritional “problem” (or diagnosis) that you will be addressing.  A nutritional diagnosis is not the same as a medical diagnosis.

To communicate a nutrition diagnosis, PES statements are used. PES statements communicate the nutrition-related problem that can be improved or resolved by nutrition intervention. They help to summarize your nutrition assessment and give justification for the next steps of the nutrition intervention.

A PES statement has three components: A nutrition-related problem, the etiology (the cause or origin of the problem), and the signs and symptoms. These sections are combined in a structured sentence by the phrases “related to” and “as evidenced by,” as below:

The  PROBLEM  related to  ETIOLOGY  as evidenced by  SIGNS and SYMPTOMS

PES Statement Examples

Increased Nutrient Needs PES Statement

Increased protein and energy needs related to increased demand for wound healing as evidenced by non healing stage 3 pressure injury and unintentional weight loss of 8% in 3 months. 

PES Statement for Cancer

Inadequate oral intake related to nausea and vomiting secondary to chemotherapy treatment as evidenced by consuming <50% of energy needs for the past 4 weeks and unintentional weight loss of 5% in one month. 

Learn more about PES statements and how to write them  here .

The nutrition diagnosis can help you prioritize the main nutritional concern and focus on what you, as the nutrition professional, can actually address. 

The nutrition intervention is the plan for resolving or improving the nutrition problem identified in Step #2. 

The NCPT breaks down some categories for the nutrition intervention, including: 

• Modifying the diet, texture, nutrients, or eating/feeding environment. 
• Providing education to the client on a particular nutritional or lifestyle topic. 
• Using certain counseling skills or theoretical models to help the client implement changes.
• This could include referring to another professional or collaborating with a community partner to support the client. 

For a complete list of Nutrition Interventions,  check this resource . 

The nutrition intervention should include the plan or goal for the client as well as the steps you are going to take to implement the plan.

Take the time to ensure that your intervention is client-centered and collaborative, including: 

• Their needs and values
• The interdisciplinary team as necessary

You’ll also want to ensure that the intervention is realistic with the timeline, urgency, and level of follow-up possible. 

Once the plan has been developed for nutrition care, monitoring and evaluation is next. 

The first part of the stage is crafting a plan for how you will determine the progress being made on the goals for the client identified in Step #3. You can look at the nutrition diagnosis and intervention and create strategies for monitoring those specifically. 

Monitoring and evaluation will likely include:

• Making an  initial plan  for what data will be collected at the next interaction with the client to be used for monitoring.
• Collecting any  relevant assessment data  pertinent to the evaluation of the client.
• Monitoring  how the intervention is impacting the client. 
• Comparing the information you collect to past data, to  determine whether changes need to be made  to your diagnosis and intervention plan. 

Consider how often you can interact with the client to monitor their progress. Evaluation of how the client is doing nutritionally should be a part of each interaction with the client.

Examples of the NCP steps 1-4 combined can be found below. 

ADIME Documentation

To simplify your chart notes and documentation of the NCP, you can utilize the ADIME documentation method. ADIME is just one charting format, but it works well with the NCP, we think you’ll see why. 

ADIME stands for

• Intervention

 So.. ADIME is the steps of the Nutrition Care Process! 

Nutrition Care Process Examples

Now that we’ve covered the overall process, let’s walk through a few Nutrition Care Process examples using the ADIME structure. 

These three examples represent different areas of practice that each have their own toolkits on DSC . Many DSC video courses also include case studies so you can walk through these steps with even more specific practical examples.

For these examples, we will walk through how to go through the steps of the NCP and utilize ADIME documentation for:

• Celiac Disease
• Polycystic Ovary Syndrome (PCOS)
• Nutrition Support – Enteral Nutrition

Nutrition Care Process Example 1 – Celiac Disease New Diagnosis

This first example will show how to go through the steps of the NCP with a client who has a new diagnosis of celiac disease. 

Nutrition Care Process Step #1 – Nutrition Assessment

The nutritional assessment for a client newly diagnosed with celiac disease might include obtaining data related to:

• Normal food intake (could be determined with a 3-day food record or 24-hour recall)
• Knowledge, beliefs, attitudes related to celiac disease and their diagnosis
• Relevant eating behaviors (how many meals and snacks they normally eat, what their eating schedule looks like, where and how they obtain food, etc.)
• Overall lifestyle and physical activity details
• Stress level
• Any relevant family or social history
• Any history of dieting or elimination diets 
• Any supplements or medications they might be taking that could impact their nutritional status
• Food access and ability to purchase gluten-free foods
• Height, weight, and weight history if weight change is a concern for the client
• Celiac diagnosis (serology screen, biopsy performed)
• Concurrent conditions 
• Lab Values (CBC, Iron, Folate, Vitamin B12, Calcium, Albumin, Phosphate, ALP, Vitamin D, Vitamin B6, Copper, Zinc)
• Any other confirmed allergies, intolerances (ie. lactose)
• Any other relevant or concurrent medical conditions (Type-1 Diabetes, Inflammatory Bowel Diseases, Arthritis, etc.)
• Loose stool
• Constipation
• Abdominal pain

Once this data is obtained, you could assess for:

• Sources of gluten in the diet
• Sources of gluten cross-contact
• Client readiness and motivation for change
• Overall dietary quality and nutrient intake (ex: adequate Fiber, Calcium, Vitamin D, Iron, Vitamin B12, Folate)

Nutrition Care Process Step #2 – Nutrition Diagnosis

The diagnosis would be individualized to the unique client and whether there is something that comes up in your assessment as a problem that needs to be addressed first.

If the main issue is that the client is completely new to the concept of celiac disease and a gluten-free diet, a nutrition diagnosis with a “limited food and nutrition knowledge” problem might make the most sense here such as in the example below:

Limited food and nutrition-related knowledge related to newly diagnosed celiac disease as evidenced by 3-day food record showing consumption of foods containing gluten and client report of lack of celiac-disease related knowledge. 

For help with building your PES statement, check out our FREE PES Statement Cheat Sheet .

Nutrition Care Process Step #3 – Nutrition Intervention

If the main problem is a knowledge deficit, nutrition education would be the main nutrition intervention. In this case, education may be around:

• The identification of gluten-containing foods
• Label reading
• Gluten cross-contamination
• Gluten-free food choices

Depending on the client’s dietary intake, education on maintaining an overall nutritionally adequate diet with fiber and micronutrients and correcting any nutrient deficiencies may also be necessary. 

For a client who does not have a knowledge deficit but is having difficulty maintaining a gluten-free diet, nutrition counseling, such as motivational interviewing, may be ideal as an intervention. 

Nutrition Care Process Step #4 – Nutrition Monitoring and Evaluation

A monitoring plan for a client newly diagnosed with celiac disease may include food tracking, which could be used to assess compliance to a gluten-free diet, nutritional adequacy, and diet quality at future appointments. 

Other considerations for monitoring may include changes in digestive symptoms, changes in lab values including nutrient deficiencies, changes in motivation level, or personal factors that may impact diet compliance. 

Nutrition Care Process Example 2 – Polycystic Ovary Syndrome (PCOS)

This example will show how to go through the steps of the NCP with a client who has PCOS. 

The nutritional assessment for a client with PCOS might include obtaining data related to:

• Weight concerns, cravings, fatigue, stress, subfertility
• Intake (3-day food record / 24-hour recall)
• Client concerns
• Knowledge/beliefs/attitudes related to food
• Eating behaviors
• Readiness/motivation to change
• Access to food
• Lifestyle / physical activity
• Medications or supplements
• Height, weight, weight history
• Commonly elevated: Total Testosterone, Free Testosterone, DHEA-S, Fasting Glucose
• Commonly deficient: Zinc, Vitamin D, Magnesium, Vitamin B12
• Relevant medical history or history of concurrent conditions (ex. diabetes)
• Lab values: 
• Client concerns of acne, hirsutism, digestive issues, etc. 
• Relevant family history of PCOS 
• Fertility concerns
• Glycemic index of the majority of carbohydrates eaten
• Overall fiber intake
• Zinc, Vitamin D, Magnesium, Vitamin B12 (if deficient or suspected deficiency)
• Anti-inflammatory vs. pro-inflammatory foods
• Fluid intake (sugar-sweetened beverages, alcohol)
• Meal and snack frequency
• Macronutrient distribution

Your nutrition diagnosis would be individualized to the unique client and any pertinent concerns the client may have. 

In an outpatient setting, it can sometimes be tricky to choose a main problem to focus on. Considering the client’s needs and desires and practical interventions may be helpful in choosing a problem to focus on first. 

For example, if the client you are seeing could benefit from eating more fiber and this is a goal your client is eager to achieve, it may make sense to start here. 

PES statement example: 

Inadequate fiber intake related to low intake of whole grains, fruits, vegetables, and legumes as evidenced by 3-day food record, postprandial hyperglycemia trends on CGM, and client concerns of feeling hungry shortly after meals.

Depending on the unique needs of the client, the intervention may focus on education related to:

• Choosing higher fiber or lower glycemic index foods
• Meal and snack timing and frequency
• Mindful eating
• Anti-inflammatory foods
• Blood glucose management

Or, focusing on nutrient supplementation, including:

• Addressing any nutrient deficiencies determined from lab value or intake assessment

Intervention may also be counseling related, with a focus on goal setting or motivational interviewing.

A monitoring plan for a client with PCOS may focus on the client’s self-tracking of their food intake, a food and mood diary, changes in lab values or blood glucose management, and/or physical findings (ex. weight changes) if that was a focus of the intervention. 

Evaluation will depend significantly on the client’s goals. In the case of the diagnosis of inadequate fiber intake, and a planned intervention to address that, the evaluation may be related to assessing the client’s food records for changes to the estimated intake of fiber. 

Nutrition Care Process Example 3 – Nutrition Support (Enteral Nutrition)

This final example will show how to go through the steps of the NCP with a client who has been referred to the dietitian for an enteral nutrition plan. 

The nutritional assessment for a client referred for enteral nutrition might include obtaining data related to:

• Nutrition and intake history (per OS intake or days NPO)
• Current body weight
• Usual body weight
• Biochemical data related to enteral feeding
• Clinical or medical data related to enteral feeding
• Any nutrient deficiencies on labs
• Current medications
• Any past or planned surgeries or procedures
• Physical appearance
• Skin fold thickness and mid-arm circumference
• Swallowing ability
• Digestive capabilities (ex. bowel sounds)
• Any nausea, vomiting, diarrhea concerns
• Any relevant family, social, or personal history
• Financial means to afford enteral formula
• Results from a malnutrition screening tool

Your assessment will also include the client’s energy, protein, and fluid needs.

In a clinical setting, where enteral nutrition is recommended or considered, the nutrition diagnosis is often related to intake. For a diagnosis related to intake, the intervention of enteral nutrition will address this problem. Diagnosis related to inadequate or inappropriate enteral or parenteral nutrition may also be considered if the client is already prescribed nutrition support and is in need of a change of formula or delivery method. 

Clinical status, including involuntary weight loss, may also be considered the main problem. 

Example PES statement:

Inadequate oral intake related to swallowing difficulties as evidenced by abnormal swallow study, unintentional weight loss of 6% in 1 month, low mid-arm circumference, and low hemoglobin levels. 

Compared to the previous examples, where education and counseling were the most logical interventions, in this situation “Food and/or Nutrient Delivery” will be the category of intervention to address.

Your intervention may be related to some or all of the following:

• Determining feeding access
• Determining the feeding schedule
• Calculating energy, protein and fluid requirements
• Determining the formula and total amount required to meet needs
• Determining the feeding rate to meet goal
• Determining the risk of refeeding
• Calculating water flushes

From this, the final enteral prescription will be the main intervention, along with any goals for weight gain and education required. Referral to community supports may also be a part of the intervention. 

Monitoring enteral tolerance will include looking at:

• Energy, protein, and fluid intake
• Gastrointestinal symptoms and changes
• Blood work changes
• Weight changes
• Tube placement
• Medication changes
• “Ins and Outs” (nutritional intake and bladder and bowel outputs)

Evaluation of any changes in nutrition indicators may require future interventions related to transitioning to bolus feeds prior to discharge to improve normalcy, ensuring enteral formula is covered for home use, trialing oral intake if possible, weaning off of enteral nutrition, and collaborating with community supports. 

Key Takeaways for Dietitians

• The Nutrition Care Process (NCP) involves 4 steps: assessment, diagnosis, intervention, and monitoring and evaluation.
• Dietitians can use the NCP as a consistent methodology to guide nutritional care.
• ADIME charting incorporates the steps of the NCP into a documentation style.
• Nutrition Care Process Terminology (NCPT) can be used as part of the NCP to communicate the assessment, diagnosis, intervention, monitoring & evaluation.

Looking for more practical education designed for Registered Dietitians and nutrition practitioners? DSC is home to hundreds of online courses, ready-to-use client handouts, and practitioner resources designed to save you time while expanding your skills & knowledge. Become a DSC member today to access all of our toolkits and learn more about topics like celiac disease, polycystic ovary syndrome, enteral nutrition, and many more!

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Case 6–2020: A 34-Year-Old Woman with Hyperglycemia

Presentation of case.

Dr. Max C. Petersen (Medicine): A 34-year-old woman was evaluated in the diabetes clinic of this hospital for hyperglycemia.

Eleven years before this presentation, the blood glucose level was 126 mg per deciliter (7.0 mmol per liter) on routine laboratory evaluation, which was performed as part of an annual well visit. The patient could not recall whether she had been fasting at the time the test had been performed. One year later, the fasting blood glucose level was 112 mg per deciliter (6.2 mmol per liter; reference range, <100 mg per deciliter [<5.6 mmol per liter]).

Nine years before this presentation, a randomly obtained blood glucose level was 217 mg per deciliter (12.0 mmol per liter), and the patient reported polyuria. At that time, the glycated hemoglobin level was 5.8% (reference range, 4.3 to 5.6); the hemoglobin level was normal. One year later, the glycated hemoglobin level was 5.9%. The height was 165.1 cm, the weight 72.6 kg, and the body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) 26.6. The patient received a diagnosis of prediabetes and was referred to a nutritionist. She made changes to her diet and lost 4.5 kg of body weight over a 6-month period; the glycated hemoglobin level was 5.5%.

Six years before this presentation, the patient became pregnant with her first child. Her prepregnancy BMI was 24.5. At 26 weeks of gestation, the result of a 1-hour oral glucose challenge test (i.e., the blood glucose level obtained 1 hour after the oral administration of a 50-g glucose load in the nonfasting state) was 186 mg per deciliter (10.3 mmol per liter; reference range, <140 mg per deciliter [<7.8 mmol per liter]). She declined a 3-hour oral glucose tolerance test; a presumptive diagnosis of gestational diabetes was made. She was asked to follow a meal plan for gestational diabetes and was treated with insulin during the pregnancy. Serial ultrasound examinations for fetal growth and monitoring were performed. At 34 weeks of gestation, the fetal abdominal circumference was in the 76th percentile for gestational age. Polyhydramnios developed at 37 weeks of gestation. The child was born at 39 weeks 3 days of gestation, weighed 3.9 kg at birth, and had hypoglycemia after birth, which subsequently resolved. Six weeks post partum, the patient’s fasting blood glucose level was 120 mg per deciliter (6.7 mmol per liter), and the result of a 2-hour oral glucose tolerance test (i.e., the blood glucose level obtained 2 hours after the oral administration of a 75-g glucose load in the fasting state) was 131 mg per deciliter (7.3 mmol per liter; reference range, <140 mg per deciliter). Three months post partum, the glycated hemoglobin level was 6.1%. Lifestyle modification for diabetes prevention was recommended.

Four and a half years before this presentation, the patient became pregnant with her second child. Her prepregnancy BMI was 25.1. At 5 weeks of gestation, she had an elevated blood glucose level. Insulin therapy was started at 6 weeks of gestation, and episodes of hypoglycemia occurred during the pregnancy. Serial ultrasound examinations for fetal growth and monitoring were performed. At 28 weeks of gestation, the fetal abdominal circumference was in the 35th percentile for gestational age, and the amniotic fluid level was normal. Labor was induced at 38 weeks of gestation; the child weighed 2.6 kg at birth. Neonatal blood glucose levels were reported as stable after birth. Six weeks post partum, the patient’s fasting blood glucose level was 133 mg per deciliter (7.4 mmol per liter), and the result of a 2-hour oral glucose tolerance test was 236 mg per deciliter (13.1 mmol per liter). The patient received a diagnosis of type 2 diabetes mellitus; lifestyle modification was recommended. Three months post partum, the glycated hemoglobin level was 5.9% and the BMI was 30.0. Over the next 2 years, she followed a low-carbohydrate diet and regular exercise plan and self-monitored the blood glucose level.

Two years before this presentation, the patient became pregnant with her third child. Blood glucose levels were again elevated, and insulin therapy was started early in gestation. She had episodes of hypoglycemia that led to adjustment of her insulin regimen. The child was born at 38 weeks 5 days of gestation, weighed 3.0 kg at birth, and had hypoglycemia that resolved 48 hours after birth. After the birth of her third child, the patient started to receive metformin, which had no effect on the glycated hemoglobin level, despite adjustment of the therapy to the maximal dose.

One year before this presentation, the patient became pregnant with her fourth child. Insulin therapy was again started early in gestation. The patient reported that episodes of hypoglycemia occurred. Polyhydramnios developed. The child was born at 38 weeks 6 days of gestation and weighed 3.5 kg. The patient sought care at the diabetes clinic of this hospital for clarification of her diagnosis.

The patient reported following a low-carbohydrate diet and exercising 5 days per week. There was no fatigue, change in appetite, change in vision, chest pain, shortness of breath, polydipsia, or polyuria. There was no history of anemia, pancreatitis, hirsutism, proximal muscle weakness, easy bruising, headache, sweating, tachycardia, gallstones, or diarrhea. Her menstrual periods were normal. She had not noticed any changes in her facial features or the size of her hands or feet.

The patient had a history of acne and low-back pain. Her only medication was metformin. She had no known medication allergies. She lived with her husband and four children in a suburban community in New England and worked as an administrator. She did not smoke tobacco or use illicit drugs, and she rarely drank alcohol. She identified as non-Hispanic white. Both of her grandmothers had type 2 diabetes mellitus. Her father had hypertension, was overweight, and had received a diagnosis of type 2 diabetes at 50 years of age. Her mother was not overweight and had received a diagnosis of type 2 diabetes at 48 years of age. The patient had two sisters, neither of whom had a history of diabetes or gestational diabetes. There was no family history of hemochromatosis.

On examination, the patient appeared well. The blood pressure was 126/76 mm Hg, and the heart rate 76 beats per minute. The BMI was 25.4. The physical examination was normal. The glycated hemoglobin level was 6.2%.

A diagnostic test was performed.

DIFFERENTIAL DIAGNOSIS

Dr. Miriam S. Udler: I am aware of the diagnosis in this case and participated in the care of this patient. This healthy 34-year-old woman, who had a BMI just above the upper limit of the normal range, presented with a history of hyperglycemia of varying degrees since 24 years of age. When she was not pregnant, she was treated with lifestyle measures as well as metformin therapy for a short period, and she maintained a well-controlled blood glucose level. In thinking about this case, it is helpful to characterize the extent of the hyperglycemia and then to consider its possible causes.

CHARACTERIZING HYPERGLYCEMIA

This patient’s hyperglycemia reached a threshold that was diagnostic of diabetes 1 on two occasions: when she was 25 years of age, she had a randomly obtained blood glucose level of 217 mg per deciliter with polyuria (with diabetes defined as a level of ≥200 mg per deciliter [≥11.1 mmol per liter] with symptoms), and when she was 30 years of age, she had on the same encounter a fasting blood glucose level of 133 mg per deciliter (with diabetes defined as a level of ≥126 mg per deciliter) and a result on a 2-hour oral glucose tolerance test of 236 mg per deciliter (with diabetes defined as a level of ≥200 mg per deciliter). On both of these occasions, her glycated hemoglobin level was in the prediabetes range (defined as 5.7 to 6.4%). In establishing the diagnosis of diabetes, the various blood glucose studies and glycated hemoglobin testing may provide discordant information because the tests have different sensitivities for this diagnosis, with glycated hemoglobin testing being the least sensitive. 2 Also, there are situations in which the glycated hemoglobin level can be inaccurate; for example, the patient may have recently received a blood transfusion or may have a condition that alters the life span of red cells, such as anemia, hemoglobinopathy, or pregnancy. 3 These conditions were not present in this patient at the time that the glycated hemoglobin measurements were obtained. In addition, since the glycated hemoglobin level reflects the average glucose level typically over a 3-month period, discordance with timed blood glucose measurements can occur if there has been a recent change in glycemic control. This patient had long-standing mild hyperglycemia but met criteria for diabetes on the basis of the blood glucose levels noted.

Type 1 and Type 2 Diabetes

Now that we have characterized the patient’s hyperglycemia as meeting criteria for diabetes, it is important to consider the possible types. More than 90% of adults with diabetes have type 2 diabetes, which is due to progressive loss of insulin secretion by beta cells that frequently occurs in the context of insulin resistance. This patient had received a diagnosis of type 2 diabetes; however, some patients with diabetes may be given a diagnosis of type 2 diabetes on the basis of not having features of type 1 diabetes, which is characterized by autoimmune destruction of the pancreatic beta cells that leads to rapid development of insulin dependence, with ketoacidosis often present at diagnosis.

Type 1 diabetes accounts for approximately 6% of all cases of diabetes in adults (≥18 years of age) in the United States, 4 and 80% of these cases are diagnosed before the patient is 20 years of age. 5 Since this patient’s diabetes was essentially nonprogressive over a period of at least 9 years, she most likely does not have type 1 diabetes. It is therefore not surprising that she had received a diagnosis of type 2 diabetes, but there are several other types of diabetes to consider, particularly since some features of her case do not fit with a typical case of type 2 diabetes, such as her age at diagnosis, the presence of hyperglycemia despite a nearly normal BMI, and the mild and nonprogressive nature of her disease over the course of many years.

Less Common Types of Diabetes

Latent autoimmune diabetes in adults (LADA) is a mild form of autoimmune diabetes that should be considered in this patient. However, there is controversy as to whether LADA truly represents an entity that is distinct from type 1 diabetes. 6 Both patients with type 1 diabetes and patients with LADA commonly have elevated levels of diabetes-associated autoantibodies; however, LADA has been defined by an older age at onset (typically >25 years) and slower progression to insulin dependence (over a period of >6 months). 7 This patient had not been tested for diabetes-associated autoantibodies. I ordered these tests to help evaluate for LADA, but this was not my leading diagnosis because of her young age at diagnosis and nonprogressive clinical course over a period of at least 9 years.

If the patient’s diabetes had been confined to pregnancy, we might consider gestational diabetes, but she had hyperglycemia outside of pregnancy. Several medications can cause hyperglycemia, including glucocorticoids, atypical antipsychotic agents, cancer immunotherapies, and some antiretroviral therapies and immunosuppressive agents used in transplantation. 8 However, this patient was not receiving any of these medications. Another cause of diabetes to consider is destruction of the pancreas due to, for example, cystic fibrosis, a tumor, or pancreatitis, but none of these were present. Secondary endocrine disorders — including excess cortisol production, excess growth hormone production, and pheochromocytoma — were considered to be unlikely in this patient on the basis of the history, review of symptoms, and physical examination.

Monogenic Diabetes

A final category to consider is monogenic diabetes, which is caused by alteration of a single gene. Types of monogenic diabetes include maturity-onset diabetes of the young (MODY), neonatal diabetes, and syndromic forms of diabetes. Monogenic diabetes accounts for 1 to 6% of cases of diabetes in children 9 and approximately 0.4% of cases in adults. 10 Neonatal diabetes is diagnosed typically within the first 6 months of life; syndromic forms of monogenic diabetes have other abnormal features, including particular organ dysfunction. Neither condition is applicable to this patient.

MODY is an autosomal dominant condition characterized by primary pancreatic beta-cell dysfunction that causes mild diabetes that is diagnosed during adolescence or early adulthood. As early as 1964, the nomenclature “maturity-onset diabetes of the young” was used to describe cases that resembled adult-onset type 2 diabetes in terms of the slow progression to insulin use (as compared with the rapid progression in type 1 diabetes) but occurred in relatively young patients. 11 Several genes cause distinct forms of MODY that have specific disease features that inform treatment, and thus MODY is a clinically important diagnosis. Most forms of MODY cause isolated abnormal glucose levels (in contrast to syndromic monogenic diabetes), a manifestation that has contributed to its frequent misdiagnosis as type 1 or type 2 diabetes. 12

Genetic Basis of MODY

Although at least 13 genes have been associated with MODY, 3 genes — GCK , which encodes glucokinase, and HNF1A and HNF4A , which encode hepatocyte nuclear factors 1A and 4A, respectively — account for most cases. MODY associated with GCK (known as GCK-MODY) is characterized by mild, nonprogressive hyperglycemia that is present since birth, whereas the forms of MODY associated with HNF1A and HNF4A (known as HNF1A-MODY and HNF4A-MODY, respectively) are characterized by the development of diabetes, typically in the early teen years or young adulthood, that is initially mild and then progresses such that affected patients may receive insulin before diagnosis.

In patients with GCK-MODY, genetic variants reduce the function of glucokinase, the enzyme in pancreatic beta cells that functions as a glucose sensor and controls the rate of entry of glucose into the glycolytic pathway. As a result, reduced sensitivity to glucose-induced insulin secretion causes asymptomatic mild fasting hyperglycemia, with an upward shift in the normal range of the fasting blood glucose level to 100 to 145 mg per deciliter (5.6 to 8.0 mmol per liter), and also causes an upward shift in postprandial blood glucose levels, but with tight regulation maintained ( Fig. 1 ). 13 This mild hyperglycemia is not thought to confer a predisposition to complications of diabetes, 14 is largely unaltered by treatment, 15 and does not necessitate treatment outside of pregnancy.

Key features suggesting maturity-onset diabetes of the young (MODY) in this patient were an age of less than 35 years at the diagnosis of diabetes, a strong family history of diabetes with an autosomal dominant pattern of inheritance, and hyperglycemia despite a close-to-normal body-mass index. None of these features is an absolute criterion. MODY is caused by single gene–mediated disruption of pancreatic beta-cell function. In MODY associated with the GCK gene (known as GCK-MODY), disrupted glucokinase function causes a mild upward shift in glucose levels through-out the day and does not necessitate treatment. 13 In the pedigree, circles represent female family members, squares male family members, blue family members affected by diabetes, and green unaffected family members. The arrow indicates the patient.

In contrast to GCK-MODY, the disorders HNF1A-MODY and HNF4A-MODY result in progressive hyperglycemia that eventually leads to treatment. 16 Initially, there may be a normal fasting glucose level and large spikes in postprandial glucose levels (to >80 mg per deciliter [>4.4 mmol per liter]). 17 Patients can often be treated with oral agents and discontinue insulin therapy started before the diagnosis of MODY. 18 Of note, patients with HNF1A-MODY or HNF4A-MODY are typically sensitive to treatment with sulfonylureas 19 but may also respond to glucagon-like peptide-1 receptor agonists. 20

This patient had received a diagnosis of diabetes before 35 years of age, had a family history of diabetes involving multiple generations, and was not obese. These features are suggestive of MODY but do not represent absolute criteria for the condition ( Fig. 1 ). 1 Negative testing for diabetes-associated autoantibodies would further increase the likelihood of MODY. There are methods to calculate a patient’s risk of having MODY associated with GCK , HNF1A , or HNF4A . 21 , 22 Using an online calculator ( www.diabetesgenes.org/mody-probability-calculator ), we estimate that the probability of this patient having MODY is at least 75.5%. Genetic testing would be needed to confirm this diagnosis, and in patients at an increased risk for MODY, multigene panel testing has been shown to be cost-effective. 23 , 24

DR. MIRIAM S. UDLER’S DIAGNOSIS

Maturity-onset diabetes of the young, most likely due to a GCK variant.

DIAGNOSTIC TESTING

Dr. Christina A. Austin-Tse: A diagnostic sequencing test of five genes associated with MODY was performed. One clinically significant variant was identified in the GCK gene ( {"type":"entrez-nucleotide","attrs":{"text":"NM_000162.3","term_id":"167621407","term_text":"NM_000162.3"}} NM_000162.3 ): a c.787T→C transition resulting in the p.Ser263Pro missense change. Review of the literature and variant databases revealed that this variant had been previously identified in at least three patients with early-onset diabetes and had segregated with disease in at least three affected members of two families (GeneDx: personal communication). 25 , 26 Furthermore, the variant was rare in large population databases (occurring in 1 out of 128,844 European chromosomes in gnomAD 27 ), a feature consistent with a disease-causing role. Although the serine residue at position 263 was not highly conserved, multiple in vitro functional studies have shown that the p.Ser263Pro variant negatively affects the stability of the glucokinase enzyme. 26 , 28 – 30 As a result, this variant met criteria to be classified as “likely pathogenic.” 31 As mentioned previously, a diagnosis of GCK-MODY is consistent with this patient’s clinical features. On subsequent testing of additional family members, the same “likely pathogenic” variant was identified in the patient’s father and second child, both of whom had documented hyperglycemia.

DISCUSSION OF MANAGEMENT

Dr. Udler: In this patient, the diagnosis of GCK-MODY means that it is normal for her blood glucose level to be mildly elevated. She can stop taking metformin because discontinuation is not expected to substantially alter her glycated hemoglobin level 15 , 32 and because she is not at risk for complications of diabetes. 14 However, she should continue to maintain a healthy lifestyle. Although patients with GCK-MODY are not typically treated for hyperglycemia outside of pregnancy, they may need to be treated during pregnancy.

It is possible for a patient to have type 1 or type 2 diabetes in addition to MODY, so this patient should be screened for diabetes according to recommendations for the general population (e.g., in the event that she has a risk factor for diabetes, such as obesity). 1 Since the mild hyperglycemia associated with GCK-MODY is asymptomatic (and probably unrelated to the polyuria that this patient had described in the past), the development of symptoms of hyperglycemia, such as polyuria, polydipsia, or blurry vision, should prompt additional evaluation. In patients with GCK-MODY, the glycated hemoglobin level is typically below 7.5%, 33 so a value rising above that threshold or a sudden large increase in the glycated hemoglobin level could indicate concomitant diabetes from another cause, which would need to be evaluated and treated.

This patient’s family members are at risk for having the same GCK variant, with a 50% chance of offspring inheriting a variant from an affected parent. Since the hyperglycemia associated with GCK-MODY is present from birth, it is necessary to perform genetic testing only in family members with demonstrated hyperglycemia. I offered site-specific genetic testing to the patient’s parents and second child.

Dr. Meridale V. Baggett (Medicine): Dr. Powe, would you tell us how you would treat this patient during pregnancy?

Dr. Camille E. Powe: During the patient’s first pregnancy, routine screening led to a presumptive diagnosis of gestational diabetes, the most common cause of hyperglycemia in pregnancy. Hyperglycemia in pregnancy is associated with adverse pregnancy outcomes, 34 and treatment lowers the risk of such outcomes. 35 , 36 Two of the most common complications — fetal overgrowth (which can lead to birth injuries, shoulder dystocia, and an increased risk of cesarean delivery) and neonatal hypoglycemia — are thought to be the result of fetal hyperinsulinemia. 37 Maternal glucose is freely transported across the placenta, and excess glucose augments insulin secretion from the fetal pancreas. In fetal life, insulin is a potent growth factor, and neonates who have hyperinsulinemia in utero often continue to secrete excess insulin in the first few days of life. In the treatment of pregnant women with diabetes, we strive for strict blood sugar control (fasting blood glucose level, <95 mg per deciliter [<5.3 mmol per liter]; 2-hour postprandial blood glucose level, <120 mg per deciliter) to decrease the risk of these and other hyperglycemia-associated adverse pregnancy outcomes. 38 – 40

In the third trimester of the patient’s first pregnancy, obstetrical ultrasound examination revealed a fetal abdominal circumference in the 76th percentile for gestational age and polyhydramnios, signs of fetal exposure to maternal hyperglycemia. 40 – 42 Case series involving families with GCK-MODY have shown that the effect of maternal hyperglycemia on the fetus depends on whether the fetus inherits the pathogenic GCK variant. 43 – 48 Fetuses that do not inherit the maternal variant have overgrowth, presumably due to fetal hyperinsulinemia ( Fig. 2A ). In contrast, fetuses that inherit the variant do not have overgrowth and are born at a weight that is near the average for gestational age, despite maternal hyperglycemia, presumably because the variant results in decreased insulin secretion ( Fig. 2B ). Fetuses that inherit GCK-MODY from their fathers and have euglycemic mothers appear to be undergrown, most likely because their insulin secretion is lower than normal when they and their mothers are euglycemic ( Fig. 2D ). Because fetal overgrowth and polyhydramnios occurred during this patient’s first pregnancy and neonatal hypoglycemia developed after the birth, the patient’s first child is probably not affected by GCK-MODY.

Pathogenic variants that lead to GCK-MODY, when carried by a fetus, change the usual relationship of maternal hyperglycemia to fetal hyperinsulinemia and fetal overgrowth. GCK-MODY–affected fetuses have lower insulin secretion than unaffected fetuses in response to the same maternal blood glucose level. In a hyperglycemic mother carrying a fetus who is unaffected by GCK-MODY, excessive fetal growth is usually apparent (Panel A). Studies involving GCK-MODY–affected hyperglycemic mothers have shown that fetal growth is normal despite maternal hyperglycemia when a fetus has the maternal GCK variant (Panel B). The goal of treatment of maternal hyperglycemia when a fetus is unaffected by GCK-MODY is to establish euglycemia to normalize fetal insulin levels and growth (Panel C); whether this can be accomplished in the case of maternal GCK-MODY is controversial, given the genetically determined elevated maternal glycemic set point. In the context of maternal euglycemia, GCK-MODY–affected fetuses may be at risk for fetal growth restriction (Panel D).

In accordance with standard care for pregnant women with diabetes who do not meet glycemic targets after dietary modification, 38 , 39 the patient was treated with insulin during her pregnancies. In her second pregnancy, treatment was begun early, after hyperglycemia was detected in the first trimester. Because she had not yet received the diagnosis of GCK-MODY during any of her pregnancies, no consideration of this condition was given during her obstetrical treatment. Whether treatment affects the risk of hyperglycemia-associated adverse pregnancy outcomes in pregnant women with known GCK-MODY is controversial, with several case series showing that the birth weight percentile in unaffected neonates remains consistent regardless of whether the mother is treated with insulin. 44 , 45 Evidence suggests that it may be difficult to overcome a genetically determined glycemic set point in patients with GCK-MODY with the use of pharmacotherapy, 15 , 32 and affected patients may have symptoms of hypoglycemia when the blood glucose level is normal because of an enhanced counterregulatory response. 49 , 50 Still, to the extent that it is possible, it would be desirable to safely lower the blood glucose level in a woman with GCK-MODY who is pregnant with an unaffected fetus in order to decrease the risk of fetal overgrowth and other consequences of mildly elevated glucose levels ( Fig. 2C ). 46 , 47 , 51 In contrast, there is evidence that lowering the blood glucose level in a pregnant woman with GCK-MODY could lead to fetal growth restriction if the fetus is affected ( Fig. 2D ). 45 , 52 During this patient’s second pregnancy, she was treated with insulin beginning in the first trimester, and her daughter’s birth weight was near the 16th percentile for gestational age; this outcome is consistent with the daughter’s ultimate diagnosis of GCK-MODY.

Expert opinion suggests that, in pregnant women with GCK-MODY, insulin therapy should be deferred until fetal growth is assessed by means of ultrasound examination beginning in the late second trimester. If there is evidence of fetal overgrowth, the fetus is presumed to be unaffected by GCK-MODY and insulin therapy is initiated. 53 After I have counseled women with GCK-MODY on the potential risks and benefits of insulin treatment during pregnancy, I have sometimes used a strategy of treating hyperglycemia from early in pregnancy using modified glycemic targets that are less stringent than the targets typically used during pregnancy. This strategy attempts to balance the risk of growth restriction in an affected fetus (as well as maternal hypoglycemia) with the potential benefit of glucose-lowering therapy for an unaffected fetus.

Dr. Udler: The patient stopped taking metformin, and subsequent glycated hemoglobin levels remained unchanged, at 6.2%. Her father and 5-year-old daughter (second child) both tested positive for the same GCK variant. Her father had a BMI of 36 and a glycated hemoglobin level of 7.8%, so I counseled him that he most likely had type 2 diabetes in addition to GCK-MODY. He is currently being treated with metformin and lifestyle measures. The patient’s daughter now has a clear diagnosis to explain her hyperglycemia, which will help in preventing misdiagnosis of type 1 diabetes, given her young age, and will be important for the management of any future pregnancies. She will not need any medical follow-up for GCK-MODY until she is considering pregnancy.

FINAL DIAGNOSIS

Maturity-onset diabetes of the young due to a GCK variant.

Acknowledgments

We thank Dr. Andrew Hattersley and Dr. Sarah Bernstein for helpful comments on an earlier draft of the manuscript.

This case was presented at the Medical Case Conference.

No potential conflict of interest relevant to this article was reported.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org .

ADIME Note Template

Optimize your nutritionist services with our free ADIME downloadable note template! Elevate your dietitian practice to deliver high-quality and comprehensive client notes every time.

By Olivia Sayson on May 15, 2024.

Fact Checked by Ericka Pingol.

What Is An ADIME Note?

ADIME is an acronym that dietitians and nutritionists use to format their clinical notes for better care. They are used to assess a client's nutrition or diet health, and contain valuable information to make appropriate diagnoses and intervention plans. ADIME stands for Assessment, Diagnosis, Intervention, and Monitoring and Evaluation, which form the four main sections of the ADIME notes . Let’s take a look at what each of these headings mean.

The assessment section is for the information you gather on your client. This might include:

• Client’s history including nutrition history, social and family history
• Client’s medical history where relevant to their diet/nutrition
• Anthropometric measurements such as height, weight, BMI, arm circumference, and past weight history
• Results of medical lab tests
• Vital signs such as resting heart rate, or other biochemical measurements.

Both subjective data, such as your patient’s feelings or self-reporting of their history, and objective data, such as measurements or lab results, can also be included here.

The diagnosis section is for you to write your conclusion of your client’s primary nutritional concern. This should be supported by evidence gathered in the assessment section in order to yield a more meaningful diagnosis.

Intervention

The intervention section is for the plan for your client. Essentially, it asks what steps do you recommend for your client to address their diagnosis? This might include goals for your client, nutritional prescriptions, counseling, or educational resources.

Monitoring and Evaluation

The final section is for summing up what you will review at your next appointment, and how you will monitor your client’s progress. How will you measure your client’s progress toward their goals?

You might sometimes see these sections split into five sections, or with sub-headings under the main ADIME headings. To keep this template simple, we have provided the four widely recognized ADIME headings and left enough space for you to write your nutrition notes in your preferred style. It's a win-win.

Printable ADIME Note Template & Example

Check out these free ADIME Note Templates to enhance note-taking quality while streamlining your client workflows.

How To Use ADIME Notes in 2023

This template is designed to make it easy for you to take structured and clearly formatted nutritionist notes according to the well-known and up-to-date ADIME note structure. Follow these simple steps to start using this template in your nutrition practice. 

1. Open the template

The template can be downloaded from the link in this page, printed out, or used right from within Carepatron. However you like to take notes, the first step is to open up your template - easy as pie!

2. Fill in your client’s information 

Each ADIME note needs to have your client’s name, birth date, and the date and time of their session. Make sure to double-check this information so it is accurate and free from mistakes.

3. Reason(s) for referral

We have created a dedicated space for a short summary of your patient’s reason for referral to you as a dietitian or nutritionist. This allows for a quick version of their primary complaint rather than a comprehensive history. That way, you can get right to the bottom of their health concerns to save time.

4. Fill in the ADIME sections

The ADIME headings have been set-out for you already. Simply work through these sections with your client and fill in each area appropriately, with sufficient information to guide effective treatment plans. 

5. Sign the ADIME note and store it securely

The last step is to write your name, sign the note, and ensure the note is stored safely. This note contains confidential patient health information and so you have a legal requirement to ensure it is stored securely. Having it located in a dedicated space also allows for all your ADIME notes to be accessible for your follow-up appointments, or when you need to read over them again.

ADIME Note Example (Sample)

To help you understand the sorts of things that belong under each ADIME heading, we have created an example ADIME note using our ADIME note template. While your ADIME notes may differ, and every dietitian or nutritionist will have their own style they like to use for writing notes, this example can help to illustrate what a completed ADIME note may look like. 

Take a look at the sample completed ADIME note template here:

Who Can Use this Printable ADIME Note Template?

Our ADIME Note template was designed with Registered Dietitians and Registered Dietitian Nutritionists in mind. There are a wide variety of dietetic specialties that can benefit from using our ADIME Note templates, including:

• Pediatric nutrition
• Sports dietetics
• Obesity and weight loss nutrition
• Oncology nutrition
• Geriatric nutrition
• Public health nutrition

Additionally, student nutritionists can also benefit from using this template in their training, and it provides great evidence for clinical sign-offs.

Why Is This Template Useful For Registered Dietitians (RD) or Registered Dietitian Nutritionists (RDN)

Keep your notes organized.

Having a template that separates the key information into easy-to-find sections makes it simple for you to keep your clinical notes organized. As an RD or RDN, you will have many clients all with different needs. Using a template for your ADIME notes is the best way you can standardize your ADIME note-taking and ensure you are providing comprehensive clinical notes for all your clients. 

Structure your client’s session

This ADIME note template not only serves as a structure for your notes but can also be a great way to structure your client’s session with you. Registered Dietitians and Registered Dietitian Nutritionists may see clients for a whole range of reasons, but incorporating a structure to your sessions can help you capture all the important information you need during your session. 

Templates are an easy and effective way to standardize your note-taking practice. Keeping organized and having a set method for taking client notes in your nutrition or dietitian practice will reap many benefits, including saving you time.

Why Use Carepatron For ADIME Notes?

If you’ve just found our ADIME note template, you have made a great start to saving time and getting organized in your clinical practice ! Carepatron offers a whole range of time-saving solutions for your nutrition practice, including a wide variety of useful clinical templates, a HIPAA-compliant storage solution for your electronic health records, a patient portal for your clients, smart voice-to-text dictation software, and much more.

Access Carepatron whenever and wherever you need on desktop or mobile, manage your calendar and appointments and even conduct video sessions with your clients all from within Carepatron.

Carepatron is the healthcare workspace you have been waiting for to take your nutrition practice to the next level. Start saving time on your practice administration and get back to taking care of your clients.

Commonly asked questions

There are many different ways of formatting an ADIME note. Some formats separate Monitoring and Evaluation into two separate sections, and some include sub-headings in each section. We have kept our ADIME note template simple to allow for your preferred style of formatting, whilst providing an overarching format to the entire note to keep it readable and organized. You don't have to put in any extra effort, as the optimized format is already created for you, and ready for you to use.

ADIME stands for Assessment, Diagnosis, Intervention, and Monitoring and Evaluation.

This will differ for every client, but some details should always be included. These are the patient information such as their name and birthdate, your signature, the date of the session, and the reason for their referral to you. Within the ADIME sections, it is up to your clinical judgment to determine what is important. Commonly, you will see anthropometric measurements such as height and weight included, as well as goals for your patient, and your strategy for monitoring their progress.

Yes, ADIME notes can be used for diabetes and malnutrition related issues. ADIME notes can be used for any diet or nutritional health related assessments, plans, or evaluations.

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• November 9, 2021
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How to Write a PES Statement (with Examples!)

You’ve had a great interaction with a nutrition client and now, the time has come: you have to complete your chart…complete with the PES statement. Yikes!

PES statements can feel confusing for RDs and RD2Bes alike. But take heart: this post will provide you with tricks and tools to help you feel more confident as you write your next PES statement. Plus, we have examples of PES Statements from different niches.

If you’ve been looking for help with PES Statements before, you may have noticed how many articles are very high-level…where are the actual PES statement examples? And you probably don’t want to be lugging a book with you as you move from patient to patient to support your charting.

In this blog post, you’re invited to refresh your memory about what PES statements are, their intention to provide for better patient outcomes as well as several examples for you to actually see PES statement examples in action. You’re probably going to want to bookmark this post for later!

Let’s dive in!

What is a PES Statement?

What is a PES Statement exactly? A PES statement is one part of the formal charting process that dietitians can use in a hospital setting, in a long-term care facility, or in their private practice. 

The purpose of the PES statement is to clearly state what the RD will be doing to improve the health and wellness of the patient, with changes or optimizations to the patient’s nutrition intake, education, or access to safe food.

Dietitians have been encouraged to use the ADIME format for charting since its inception in 2003 ( 1 ). The formal charting note captures the patient or client’s medical and health history, medical diagnosis, as well as their nutrition status and plans for improving any nutrition issues.

ADIME is an acronym for:

The Etiology is the dietitian’s assessment of why this nutrition diagnosis happened to begin with. Ask yourself what is the root cause of the nutrition problem?

As dietitians, the etiology section of the PES statement is aimed to address the nutritional problem that you are solving with your work.

You may find it helpful to start at the etiology section and work backward from there. This strategy can help prevent you from feeling stuck if you aren’t quite sure where to start with the PES statement.

Signs/Symptoms

This part of the PES statement is where the RD provides the evidence to support why they diagnosed the nutrition problem, to begin with. What is the objective (such as a lab or anthropometric value) and subjective (such as a food recall) data to support the claim? 

The PES statement, within the ADMIE note, is part of the larger process of providing nutrition care as a whole. This is known at the NCP: let’s explore that now.

PES Statements and the Nutrition Care Process

PES Statements are one piece of the formal documentation – the ADIME note – that is part of the whole standardized methods that dietitians are taught to move through as they provide patient care.

The purpose of the Nutrition Care Process (abbreviated NCP) is to have a standardized method for providing nutrition interventions as well as a standard language used throughout the process.

The intention is that with a standardized process and language, the NCP enables patients to receive more consistent and predictable care. But more than that: the NCP allows dietitians to deliver high-quality care and outcomes for their patients. A nutrition diagnosis statement should be one that we as dietitians take accountability to address and resolve.

PES statements follow a standardized format.

The format of the PES statement is — Problem (the nutrition diagnosis) related to Etiology (the root cause of the nutrition diagnosis) as evidenced by Signs and Symptoms (findings from the nutrition assessment that determine the nutrition diagnosis).

A visual way to look at the standard PES statement format is:

( Problem ) _____________ related to ( Etiology ) _____________ as evidenced by ( Signs and symptoms ) __________________.

PES Statement Examples

Now that we’ve explored what PES statements are, how they fit into the context of charting ADIME notes as well as within the NCP at large, you’re probably ready to see some examples.

Here we will cover PES statement examples in many different niches. Seeing different examples is a great way to feel more comfortable with new skills.

Reminder: the PES statement refers to the nutrition diagnosis, not the patient’s medical diagnosis.

PES Statement for Diabetes

In this example, the PES statement might apply to a patient who is newly diagnosed with diabetes or a patient who has not yet had any nutrition education about their condition.

P: Food/nutrition-related knowledge deficit related to…

E: no prior diabetes nutrition-related education as evidenced by…

S: questions raised regarding carbohydrates and being unaware of the need to moderate them.

PES Statement for Malnutrition

In this PES example, the patient is losing weight and unable to eat adequately because of their chronic disease as well as a recent additional acute diagnosis of pneumonia.

P: Malnutrition as related to…

E: Chronic disease (hx of emphysema and recent dx of pneumonia) as evidenced by…

S: Patient’s unintentional weight loss of 7.9% of his usual body weight in the past six weeks, mild loss of muscle mass, and severe loss of fat mass, as well as inflammatory markers: elevated CRP (12mg/L) and WBC (12.4) and decreased albumin (2.8g/dL).

PES Statement for Inadequate Intake

In this example, the PES statement might be a good example appropriate for a patient who has a compromised nutrient status because of drinking alcohol in excess and not being able to eat a generally healthy diet.

P: Malnutrition and inadequate intake as related to….

E: Alcohol addiction as evidenced by…

S: Loss of appetite and limited ability to prepare and consume adequate energy and reported intake of >8 drinks per day, loss of 15% of body weight in the past 3 months, food intake of less than 50% of normal in the past month and moderate to severe signs of muscle wasting

PES Statement for Obesity

In this example, the PES statement is about a WIC patient who had gained weight quickly in her pregnancy.

P: Excessive energy intake related to…

E: High-calorie fast-food meals and sweetened drinks as evidenced by…

S: Rapid weight gain of 8 pounds per month and dietary recall

PES Statement for Cirrhosis

In this example, the patient has lost their appetite as a result of their medical diagnosis, cirrhosis.

P: Inadequate intake related to…

E: loss of appetite secondary to cirrhosis as evidenced by…

S: 10% weight loss in last 5 months.

PES Statement for Hypertension

For this PES statement example, the patient is not yet able to eat well for their diagnosis of HTN and has been eating too much sodium.

P: Excessive intake of sodium related to…

E: High intake of fast food and convenience foods as evidenced by…

P: Fluid retention and elevated blood pressure of 150/95.

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FAQs about PES Statements

You may have a few questions about PES statements. Here are a few of the common questions we have come across for PES statements.

What is the difference between PES and ADIME?

PES statements are one piece of the larger ADIME charting note format. The ADIME note is the entire documentation of the patient visit while the PES statement is one section of the ADIME note.

Where do you find PES statement terminology?

You have two options for finding the PES statement terminology.

On the website of the Academy of Nutrition and Dietetics, you can purchase a hard copy of the Abridged Nutrition Care Process Terminology (NCPT) Reference Manual: Standardized Terminology for the Nutrition Care Process . There is a discount for Academy members.

The other option is to purchase a subscription to the electronic Nutrition Care Process Terminology (eNCPT) . When you purchase the hard copy of the NCPT manual, you receive a complimentary one-year membership to the eNCPT.

What is the eNCPT?

What is the eNCPT? eNCPT is short for electronic Nutrition Care Process Terminology. This is an online hub of information related to using ADIME charting.

eNCPT is not free, but they do offer a discount for AND members as well as for students. Pricing for eNCPT can be found here .

What are the benefits of using PES statements?

The benefit of using PES statements is that you’re following the recommended formatting crafted by the Academy of Nutrition and Dietetics. In addition, you have a predictable and repeatable format to document with and you’re flexible as you change roles or employers; your documentation methods are transferable from one role to another!

What trainings are available that cover the NCP?

If you’re ready to learn more about the NCP and get an hour of CPE, you’ll want to check out the free training offered via the AND here .

What is documentation in the nutrition care process?

The Nutrition Care Process (abbreviated NCP) is the standard framework for dietitians to use as they get to know their clients’ histories, medical diagnoses, and nutritional needs.

The formal charting framework is known as ADIME and is covered in-depth earlier in this article.

Do I have to use PES Statements?

This answer will vary based on where you work or if you’re in private practice. If your hospital or long-term care facility requires PES statements, then yes, you have to use them.

If you’re in your own private practice, the decision is more in your hands. However, if you bill for insurance, it is worth checking to see if they have preferences for formatting that would be best for you to follow.

Key Takeaways: PES Statements

The PES statement is part of the Nutrition Care Process (NCP), a systematic approach to providing high-quality nutrition care. The PES Statement is one part of the ADIME note, the formal documentation of your entire encounter with your patient or client.

While any new system or terminology can take some practice to get used to, this article is a guide you can come back to as needed for a refresher as you get more familiar with using PES statements.

PES Statement How-To Guide

Put down your nutrition textbook and turn to the only PES-writing resource that you need . This 3-page guide is packed with simple visuals, examples for quick reference and a checklist. Get the Dietitian’s Guide to Writing PES Statements today.

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