Nutrition Care Process: Case Study A

Examples of Charting in Various Formats

It is recommended that practitioners document each step of the Nutrition Care Process. Typically,
documentation is entered in writing or electronically into the medical record. The Nutrition Care
Process (NCP) describes documentation of Assessment, Diagnosis, Intervention, Monitoring, and
Evaluation (ADIME) steps. In a pilot study, this format was shortened to the Assessment,
Diagnosis, and Intervention (ADI) with monitoring and evaluation incorporated into the nutrition
intervention step. Implementation of the NCP is not dependent upon a specific format for
documentation. The nutrition assessment/monitoring and evaluation, nutrition diagnostic and
nutrition intervention terminology can be incorporated into existing documentation formats such
as narrative and SOAP notes. The example below illustrates how the assessment/monitoring and
evaluation, nutrition diagnosis, PES (Problem, Etiology, Sign/symptoms) statement, and nutrition
intervention terminologies can be incorporated into narrative and SOAP notes and also illustrates
the ADIME format.

Case:
JO is a 47-year-old man who is married with three children ages 13, 15, and 17 years. JO is 511
(180 cm) tall and weighs 235 pounds (106.8 kg), BMI 32.8. While playing college baseball, JO
weighed about 185 pounds (84 kg), but when he stopped playing and began coaching, his weight
increased to 200 pounds (91kg). About 3 years ago, he took a job as a junior high school
principal. The principals job requires much more desk work, and, despite walking the halls
regularly between periods at the large urban school, JO doesnt get much exercise. He has
verbalized the need to get back in shape.

JOs family history is a concern. Both of his parents have type 2 diabetes. JOs father was forced
into retirement a year after his foot was amputated because of complications from the diabetes.
Two of JOs older brothers have been told to lose weight in order to reduce their risk of
developing type 2 diabetes. His younger sister recently gave birth to her third child and was
diagnosed with gestational diabetes during the pregnancy.

Because his first son will enter college next year, JO is thinking about the future. He is thinking
about how he will prepare for his childrens college education and, eventually, their weddings. He
would like to be healthy enough to play baseball with his grandchildren when they arrive. He is
becoming concerned about his health and realizes that he needs to do something about his weight.
A recent visit to his physician was a great relief because no problems other than obesity were
identified. The physician emphasized the importance of weight loss and referred JO to a
Registered Dietitian (RD) for a weight reduction program.

The RD interviewed JO and found:

JO was born in Mexico, but immigrated to the United States at age four with his parents. His
family owned a restaurant, and he learned to cook at an early age. He often prepares traditional
foods from Mexico and fries these foods in lard. His North American-born wife does some of the
cooking and prepares meals with meat, potatoes, fruits and vegetables, and gravy.

JO does not eat breakfast at home, stating that with five people in the house getting ready for
work and school each morning, there is too much of a rush to stop for a meal. He frequently takes
several cookies or a large muffin with him to school. He drinks several cups of coffee with sugar
and cream at his desk during the morning. He eats lunch in the school cafeteria, often requesting
large portions of meats and other foods he likes. After lunch, he usually drinks at least one
sweetened soda. He is usually at school until late afternoon, and may return for evening activities.
4th Edition: 2013
Term codes (e.g., NI-2.2) used for information. The Academy does not recommend using codes in
documentation.
On these evenings, he enjoys the all you can eat buffet at a family restaurant near his home. He
eats a variety of foods, including fruits, vegetables and salads. His weakness is flour tortillas
slathered with butter or sour cream, and he eats several with each evening meal taken at home. JO
eats dessert only on special occasions. Because the family is busy, there are plenty of snack
foods available, and he usually has an after dinner snack when he returns home from evening
activities.

JOs alcohol intake is moderate, limited to 2 or 3, 12 ounce (360 mL) cans of beer on a Friday or
Saturday night if he and his wife go out with friends. Analysis of a 24-hour diet recall combined
with a food frequency questionnaire reveals that JOs typical intake is approximately 4,200
calories/kcal (17,585 kJ)/day with about 200 grams/day of total fat, about 100 grams of saturated
fat, and about 20% of calories from sugar or other concentrated sweets.

Because his job and family require so much of his time, JO does not regularly exercise.

Nutrition Diagnosis:
Excessive Oral Intake (NI-2.2) (P) related to a knowledge deficit of portion sizes and meal
planning (E), as evidenced by weight gain of 35lbs (16 kg) during the last 3 years and estimated
oral intake of 2,200 calorie/kcal/day (9,210 kJ) more than estimated needs (S).

Nutrition Intervention:
Nutrition Prescription: Reduction of food intake to approximately 2,200 calories/kcal (9,210 kJ)
per day with approximately 30% of calories/kcal/kJ from fat and < 10% of intake from saturated
fat. Motivational interviewing (C-2.1) Client described reasons for desiring wt loss; outlined
support and barriers for change; pros and cons of current eating habits. Requests specific
guidance on healthy eating now. Wife willing to assist. Goal: Increase diet readiness to the action
stage. Collaboration and Referral of Nutrition Care, Referral to community
agencies/programs (RC-1.6) for enrollment in health center cognitive behavioral program.
Goal: Client will learn behavior change strategies to promote weight loss.

Toolkits are available from the Academy for the on-line Evidence-Based Nutrition Practice
Guidelines, based upon evidence analyses. They contain sample forms and examples
incorporating the nutrition care process steps. These are available for purchase from the Academy
Evidence Analysis Library for food and nutrition practitioners to use at the store tab at
http://www.adaevidencelibrary.com/. Food and nutrition practitioners may find useful the
extensive resources provided on the Academy Evidence Analysis Library.

4th Edition: 2013

Term codes (e.g., NI-2.2) used for information. The Academy does not recommend using codes in
documentation.
Case Study A: This table demonstrates how the weight loss program addresses JOs nutrition diagnosis, and how that nutrition diagnosis
might change over time. Content is organized to present food and nutrition-related history first, since this is the critical data set
contributed by dietitians.

Narrative Format SOAP Format ADIME Format*

Meal/snack pattern (FH-1.2.2.3) JO eats two S (subjective): Meal/snack pattern (FH-1.2.2.3) A (Assessment): Total energy intake
meals and snacks throughout the day. Food Client reports no breakfast, frequent snacking, and (FH-1.1.1.1) of 4,200 calories/kcal
intake (FH-1.2.2) includes most foods and has a large portions at lunch and dinner. He likes most (17,585 kJ)/day. Total fat
high consumption of sugar based beverages foods. Food intake (FH-1.2.2) includes most intake/saturated fat intake (FH-1.5.1)
during the day. Alcohol intake (FH-1.4.1) is foods and has a high consumption of sugar based 200 grams/day of total fat, 100 grams of
limited to social occasions. Total energy intake beverages during the day. Alcohol intake (FH- saturated fat. Sugar intake (FH-1.5.3.2)
(FH-1.1.1.1) of 4,200 calories/kcal (17,585 1.4.1) is limited to social occasions. Readiness to 20% of calories from sugar or other
kJ)/day. Total fat intake (FH-1.5.1.1) and change nutrition-related behaviors (FH-4.2.7) concentrated sweets. Readiness to
saturated fat intake (FH-1.5.1.2) with 200 indicated client is in the preparation stage of change nutrition-related behaviors
grams of fat, 100 grams of saturated fat. change. He is very concerned about his strong (FH-4.2.7) client is in the preparation
Readiness to change nutrition-related family history of diabetes and desires to lose stage of change. He is very concerned
behaviors (FH-4.2.7) client is in the preparation weight and reduce his sugar intake. Weight about his strong family history of
stage of change. He is very concerned about his change (AD-1.1.4) JO states that he has gained diabetes and desires to lose weight and
strong family history of diabetes and desires to 35lbs (16 kg) over the last 3 years. Physical reduce his sugar intake.
lose weight and reduce his sugar intake. Body activity history (FH-7.3.1) Patient took a Height/weight/BMI (AD-1.1) Ht. 511
composition/growth/weight history (AD-1.1) sedentary job 3 years ago and he rarely finds time (180 cm); weight 235lbs (106.8 kg); BMI
Height 511 (180 cm); Weight 235lbs (106.8 for exercise due to a busy work and family 32.8; waist circumference 43 inches (109
kg); BMI 32.8; waist circumference 43 inches schedule. Personal history (CH-1.1) 47 yr old, cm) indicating increased disease risk,
(109 cm), indicating increased disease risk, male, Patient/client/family medical history particularly for type 2 diabetes and
particularly for type 2 diabetes and dyslipidemia. (CH-2.1) His family history includes diabetes, but dyslipidemia; gained 35lbs (16 kg) over
Client referred for a 35lbs (16 kg) weight gain he has no current medical problems. the last 3 years. Recommended body
over the last 3 years, since taking sedentary job. weight (CS-5.1.1) Client is ~ 63lbs (28.6
Physical activity history (FH-7.3.1) Patient O (objective): Ht/Wt/BMI (AD-1.1) Ht. 511 kg) above ideal weight of 172lbs (78 kg)
does not exercise regularly. Personal history (180 cm); Current weight 235lbs (106.8 kg); BMI (Hamwi Equation). Estimated energy
(CH-1.1) He is a 47-year-old male. 32.8; waist circumference is 43 inches (109 cm) needs (CS-1.1.1) Calorie intake is
Patient/client/family medical history (FH-2.1) 1,150calorie/kcal/ (4815 kJ)/day more
His family history includes diabetes, but he has than estimated needs of 3,050
no medical problems. calorie/kcal/ (12,770 kJ)/day. Mifflin-St
Jeor Equation (CS-1.1.2) with activity
JO has a nutrition diagnosis of Excessive oral factor of 1.4.
intake (NI-2.2) related to knowledge deficit of

4th Edition: 2013

Term codes (e.g., NI-2.2) used for information. The Academy does not recommend using codes in documentation.
Case Study A: This table demonstrates how the weight loss program addresses JOs nutrition diagnosis, and how that nutrition diagnosis
might change over time. Content is organized to present food and nutrition-related history first, since this is the critical data set
contributed by dietitians.

portion size and meal planning as evidenced by A (assessment): Total energy intake (FH- D (Diagnosis): Excessive oral
weight gain of 35lbs (16 kg) over the last 3 years 1.1.1.1) of 4,200 calories/kcal (17,585 kJ)/day. food/beverage intake (NI-2.2) related to
and estimated oral intake of Total fat intake (FH-1.5.1.1) and saturated fat knowledge deficit of portion size and
1,150calorie/kcal/(4815 kJ)/day more than intake (FH-1.5.1.2) with 200 grams of fat, 100 meal planning as evidenced by weight
estimated needs of 3,050 calorie/kcal/(12,770 grams of saturated fat. Sugar intake (FH-1.5.3.2) gain of 35lbs (16 kg) over the last 3
kJ)/day. Mifflin-St Jeor Equation (CS-1.1.2) with 20% of calories from sugar or other concentrated years and estimated oral intake of
activity factor of 1.4. sweets. Readiness to change nutrition-related 1,150calorie/kcal/(4815 kJ)/day more
behaviors (FH-4.2.7) client is in the preparation than estimated needs of 3,050
His Nutrition Prescription (NP-1) is 2,200 stage of change. He is very concerned about his calorie/kcal/(12,770 kJ)/day.
calories/kcal (9,210 kJ) per day with strong family history of diabetes and desires to
approximately 30% of calories from fat and < lose weight and reduce his sugar intake. Body I (Intervention): Nutrition prescription
10% of intake from saturated fat. Conducted compartment estimates (AD-1.1.7) Waist (NP-1.1) 2,200 calories/kcal (9,210 kJ)
Motivational interviewing (C-2.1). Client circumference indicates increased disease risk, per day with approximately 30% of
described reasons for desiring wt loss; outlined particularly for type 2 diabetes and dyslipidemia. calories from fat and < 10% of intake
support and barriers for change; pros and cons from saturated fat.
of current eating habits. Requests specific Recommended body weight (CS-5.1.1) Client is Motivational interviewing (C-2.1)
guidance on healthy eating now. Wife willing to ~ 63lbs (28.6 kg) above ideal weight of 172lbs (78 Client described reasons for desiring wt
assist. Goal: Increase diet readiness to the action kg) (Hamwi Equation). Estimated energy needs loss; outlined support and barriers for
stage. Collaboration and Referral of Nutrition (CS 1.1.1) change; pros and cons of current eating
Care, Referral to community habits. Requests specific guidance on
agencies/programs (RC-1.6) for enrollment in Calorie intake is 1,150calorie/kcal/ (4815 kJ)/day diet now. Wife willing to assist. Goal:
health center cognitive behavioral program. more than estimated needs of 3,050 calorie/kcal/ Increase diet readiness to the action
Goal: Client will learn behavior change strategies (12,770 kJ)/day. Mifflin-St Jeor Equation (CS- stage.
to promote weight loss. 1.1.2) with activity factor of 1.4. Collaboration and Referral Nutrition
Care, Referral to community
Will monitor and evaluate the following: Nutrition Diagnosis: Excessive oral intake (NI- agencies/programs (RC-1.6) for
Readiness to change nutrition-related 2.2) related to knowledge deficit of portion size enrollment in health center cognitive
behaviors (FH-4.2.7) Criteria: Diet readiness to and meal planning as evidenced by weight gain of behavioral program. Goal: Client will
increase to the action stage. Weight (AD-1.1.2) 35lbs (16 kg) over the last 3 years and oral intake learn behavior change strategies to
Criteria: Lose 23 lbs (10.5 kg) in 6 months, 1-2 of 1,150calorie/kcal/(4815 kJ)/day more than promote weight loss.
lbs (0.5-1kg)/week. Percent weight change estimated needs of 3,050 calorie/kcal/(12,770
(AD-1.1.4) Criteria: Lose 10% body weigh in 6 kJ)/day.
months. Body compartment estimates (AD-
1.1.7) Criteria: Decrease waist circumference to
< 40 inches (102 cm) in 6 months.

4th Edition: 2013

Term codes (e.g., NI-2.2) used for information. The Academy does not recommend using codes in documentation.
Case Study A: This table demonstrates how the weight loss program addresses JOs nutrition diagnosis, and how that nutrition diagnosis
might change over time. Content is organized to present food and nutrition-related history first, since this is the critical data set
contributed by dietitians.

P (plan) Nutrition prescription (NP-1 2) 2,200 M&E (monitor and evaluate): Readiness
calories/kcal (9,210 kJ) per day with to change nutrition-related behaviors
approximately 30% of calories from fat and < (FH-4.2.7) Criteria: Diet readiness to
10% of intake from saturated fat. increase to the action stage. Weight
Conducted Motivational interviewing (C-2.1). (AD-1.1.2) Criteria: Lose 23 lbs (10.5
Client described reasons for desiring wt loss; kg) in 6 months, 1-2 lbs (0.5-1kg)/week.
outlined support and barriers for change; pros Percent weight change (AD-1.1.4)
and cons of current eating habits. Requests Criteria: Lose 10% body weigh in 6
specific guidance on healthy eating now. Wife months. Body compartment estimates
willing to assist. Goal: Increase diet readiness to (AD-1.1.7) Criteria: Decrease waist
the action stage. Collaboration and Referral of circumference to < 40 inches (102 cm) in
Nutrition Care, Referral to community 6 months.
agencies/programs (RC-1.6) for enrollment in
health center cognitive behavioral program. Goal:
Client will learn behavior change strategies to
promote weight loss.

M&E (monitor and evaluate) Readiness to

change nutrition-related behaviors (FH-4.2.7)
Criteria: Readiness to increase to the action stage.
Weight (AD-1.1.2) Criteria: Lose 23 lbs (10.5 kg)
in 6 months, 1-2 lbs (0.5-1kg)/week. Weight
change (AD-1.1.4) Criteria: Lose 10% body
weigh in 6 months. Body compartment
estimates (AD-1.1.7) Criteria: Decrease waist
circumference to < 40 inches (102 cm) in 6
months.

* In some settings, the ADIME format has been abbreviated to the ADI format.

4th Edition: 2013

Term codes (e.g., NI-2.2) used for information. The Academy does not recommend using codes in documentation.
Case Study A: This table demonstrates how the weight loss program addresses JOs nutrition diagnosis, and how that nutrition diagnosis
might change over time. Content is organized to present food and nutrition-related history first, since this is the critical data set
contributed by dietitians.

The following outlines follow-up notes as treatment progressed during group nutrition counseling.

Session Topic Session Details Follow-up Notes

Session 1 Diet and lifestyle Review food records A: Height/weight/BMI (AD-1.1) Weight 231 lbs (105 kg). Some progress, patient
modifications and agree on goals for lost 4 pounds (1.8 kg) in 2 weeks. Readiness to change nutrition-related behaviors
intake modification. (FH-4.2.7). Goal met. Diet readiness test indicates patient is in the action stage of
2,200 calorie/kcal change.
(9,210 kJ) meal plan D: Nutrition diagnosis continues to be Excessive oral intake (NI-2.2) related to
provided and knowledge deficit of portion size and meal planning as evidenced by weight gain of
instruction provided on 35lbs (16 kg) over the last 3 years and estimated oral intake of
portion sizes and self- 1,150calorie/kcal/(4815 kJ)/day more than estimated needs of 3,050
monitoring. calorie/kcal/(12,770 kJ)/day.
I: Nutrition counseling cognitive-behavioral theory (C-1.1) for weight
management. Strategies reviewed include: Self-monitoring (C-2.3) and Goal setting
(C-2.2). Nutrition Education-Content, Other or related topics (E-1.6) provided on
portion sizes.
M&E: Height/weight/BMI (AD-1.1) Goal is to lose 1-2 lbs (0.5-1kg)/week. Will
monitor at next visit. Self-monitoring (C-2.3) Criteria (goal): Self-monitor daily for
one week, Goal setting (C-2.2) Criteria (goal): Eat a healthy breakfast four of seven
mornings.
Amount of food (FH-1.2.2.1) Criteria: Portion sizes and number of servings
consistent with 2,200 calorie/kcal (9,210 kJ) meal plan. Current goal: Reduce
meat/cheese intake to less than 6 oz (180 mL)/day. Total energy intake (FH-1.1.1.1)
Criteria: 2,200 calorie/kcal (9,210 kJ)/day.

4th Edition: 2013

Term codes (e.g., NI-2.2) used for information. The Academy does not recommend using codes in documentation.
Case Study A: This table demonstrates how the weight loss program addresses JOs nutrition diagnosis, and how that nutrition diagnosis
might change over time. Content is organized to present food and nutrition-related history first, since this is the critical data set
contributed by dietitians.

Session Topic Session Details Follow-up Notes

Session 2 Meal planning Review food records A: Height/weight/BMI (AD-1.1) Weight 229.5 lbs (104 kg). Significant progress,
and nutrient- and goals for intake patient lost 3 pounds (1.3 kg) this week. Total energy intake (FH-1.1.1.1) 4-day of
dense foods modification. Review food record reveals ~2,450 calorie/kcal (10,260 kJ)/d intake. Significant progress
portion sizes and toward goal to conform to 2,200 calorie/kcal (9,210 kJ) meal plan. Food intake (FH-
educate on appropriate 1.1.1.1) Met goal for limiting meat and cheese intake to 6 oz (160 g)/d; consuming 4
substitutions for high- regular 12 ounce (330 mL) sodas/day. Self-monitoring (C-2.3) Some progress toward
calorie, high-fat foods. goal. Completed food diary for 4 of 7 days. Found it very helpful. Goal setting (C-
2.2) Met goal to eat a healthy breakfast 4 of 7 days.
D: Excessive oral intake (NI-2.2) related to knowledge deficit of portion size and
meal planning as evidenced by weight gain of 35lbs (16 kg) over the last 3 years and
estimated oral intake of 1,150calorie/kcal/(4815 kJ)/day more than estimated needs of
3,050 calorie/kcal/(12,770 kJ)/day.
I: Cognitive-behavioral theory (C-1.1) for weight management. Strategies
reviewed include: Self-monitoring (C-2.3), Goal setting (C-2.2), Stimulus control
(C-2.7) Goal: Client will learn behavior change strategies to promote weight loss
Nutrition Education-Content, Recommended modifications (E-1.5) provided on
the therapeutic lifestyle change diet.
M&E: Self-monitoring (C-2.3) Criteria (goal): Self-monitor 2 weekdays and 2
weekend days next week and analyze for triggers. Will monitor at next visit.
Food intake (FH-1.1.1.1) Will continue to monitor at next visit. Total energy intake
(FH-1.2.1) Will monitor at next visit. Goal setting (C-2.2) Client wishes to continue
this goal and add substitution of a no calorie beverage for soda this week. Will
monitor at next visit.
Weight (AD-1.1.2) Will monitor at next visit.

Move forward in time to Session 6

4th Edition: 2013

Term codes (e.g., NI-2.2) used for information. The Academy does not recommend using codes in documentation.
Case Study A: This table demonstrates how the weight loss program addresses JOs nutrition diagnosis, and how that nutrition diagnosis
might change over time. Content is organized to present food and nutrition-related history first, since this is the critical data set
contributed by dietitians.

Session Topic Session Details Follow-up Notes

Session 6 Weight Develop long-term A: Weight change (AD-1.1.4) Significant progress, Wt 219.5 lbs (100 kg); patient
maintenance goals. Review weight- lost 1.5 pounds (0.75 kg) this week and 11.5 lbs (5 kg) since initial visit. Goal is to
reduction strategies, lose 23 lbs (10.5 kg) within six months. Waist circumference (AD-1.1.7) is 42 (107
and discuss continued cm) and has decreased 1 (2.5 cm) over 7 weeks. Some progress. Physical activity,
weight loss and Frequency (FH-7.3.3) No change. Not successful in planning exercise time into
maintenance strategies. schedule, but will partner with PE teacher at school to exercise in AM before school.
Criteria (goal): Exercise 20 min, two times next week
D: Excessive oral intake (NI-2.2) related to knowledge deficit of portion size and
meal planning as evidenced by weight gain of 35lbs (16 kg) over the last 3 years and
estimated oral intake of 1,150calorie/kcal/(4815 kJ)/day more than estimated needs of
3,050 calorie/kcal/(12,770 kJ)/day. Physical inactivity (NB-2.1) related to competing
values as evidenced by reports of lack of activity along with lack of time to
incorporate exercise.
I: Nutrition Counseling Cognitive-behavioral theory (C-1.1) for weight
management including physical activity. Strategies reviewed include: Self-
monitoring (C-2.3), Goal setting (C-2.2), Problem solving (C-2.4), Cognitive
restructuring (C-2.8), and Relapse prevention (C-2.9).
M&E: Area and level of knowledge (FH-4.1.1) Moderate knowledge of planning
healthful meals and snacks. Continues to select healthier menu items at home and at
the school cafeteria, decided not to visit the Mexican restaurant this week. Client
outlined helpful strategies for selecting healthy choices while eating out.
Moderate knowledge of healthful food preparation methods. Client experimenting
with food preparation methods to reduce amount of saturated fat/total fat used in
cooking. Will continue to monitor in one week at booster session.
Total energy intake (FH-1.1.1.1) Met goal to reduce calorie intake to 2,200
calorie/kcal (9,210 kJ) per day. Will continue to monitor.
Weight change (AD-1.1.4) Will monitor at weekly booster sessions with an
individual appointment with the RD scheduled monthly in place of the session.
Waist circumference (AD-1.1.7) Goal is to decrease waist circumference to < 40
inches (102 cm) in 6 months.
Physical activity, Frequency (FH-7.3.3) Will continue to monitor weekly at booster
sessions.

4th Edition: 2013

Term codes (e.g., NI-2.2) used for information. The Academy does not recommend using codes in documentation.