Nutrition Therapy and Pathophysiology

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 Chapter 6 – Documentation of the Nutrition Care Process
Chapter Outline
I. Introduction
II. Charting: Documentation of the Nutrition Care Process
A. Standardized Language and Medical Abbreviations
B. Problem-Oriented Medical Records
C. Organization of Nutrition Documentation
1. SOAP
2. PES, or Problem, Etiology, Signs/Symptoms Statements
3. Assessment, Diagnosis, Intervention, Monitoring/Evaluation (ADIME)
4. IER Notes
5. Focus Notes
6. PIE Notes
7. Charting by Exception
D. Keeping a Personal Medical Notebook
E. Guidelines for All Charting
1. Confidentiality
III. Beyond Charting: An Overview of Writing in the Profession
A. The Functions, Context, Parts, and Processes of Writing
1. Rhetorical Norms
2. Levels of Discourse
3. Steps in the Writing Process
B. Reporting Your Own Research
IV. Conclusion: Your Ethos—Establishing Expertise

Classroom Activities
Activity 6-1
Items needed: None.

Conduct an oral in-class quiz over the format of SOAP note charting. Ask students which category in SOAP notes
the following items would be placed in.

The answers are listed at the end of each item (subjective = s, objective = o, assessment = a, plan = p).

• Weight loss of 5 pounds in the past month (s)

• Suggest referral to a mental health professional (p)
• Medications the patients is currently taking (o)
• PES statements (a)
• Age of the patient (o)
• Nutrition diagnosis (a)
• Patient has a peanut allergy (s)
• Printed patient education materials given to the patient (p)
• Current albumin level (o)
• Patient reports feeling nauseated (s)
• Recommend patient consume additional protein (p)
• Prioritization of the nutrition diagnoses (a)
• Goal of improving carbohydrate counting skills (p)
• Patient wears lower dentures (s)
• Kcalorie requirements (o)
• Confirmation of excessive kcalorie intake (a)

© 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
Activity 6-2
Items needed: None.

Explain to students that they will now practice writing short-term goals and expected outcomes for each goal for the
following scenario. Remind students that each outcome needs to be measurable, include a specified timeframe,
indicate how it will be measured, and encourage client participation when possible.

Scenario: Josie has been identified as being at high risk for developing anorexia nervosa. Her estimated kcalorie
needs are 2350-2500 kcalories per day. A diet analysis indicates her average daily intake for the past week has been
approximately 1200 kcalories per day (approximately 50% of her needs). Her weight has been steadily decreasing
for the past two months. She states she enjoys consuming dairy products more than any other foods and often eats
only dairy products. Josie has been referred to a registered dietitian for nutrition therapy in addition to seeing a
psychologist who specializes in eating disorders.

Possible short-term goals:

1. Patient will consume 75% of her kcalorie needs daily within one week.
2. Patient will increase the variety of her food intake from all food groups.

Possible outcomes:
• Patient will keep a food diary, recording all foods eaten, and a nutrition analysis will be completed at the next
dietitian visit.
• Patient will consume foods from at least two food groups at each meal and snack in addition to foods from the
dairy group.

Build the Bridge to Application

Cases from Medical Nutrition Therapy: A Case Study Approach, 4th edition (ISBN 1133593151) may be used in
conjunction with this chapter. All cases have application of nutrition assessment/nutrition care process information.
Many have application to basic pathophysiology. The cases listed here have a primary emphasis for the chapter
concept.

• Case 10 – Irritable Bowel Disease

• Case 32 – Acute Lymphoblastic Leukemia Treated with Hematopoietic Cell Transplantation.

© 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
 Handout 6: Examples of SOAP and ADIME Documentation
SOAP Format
Subjective data: diet, medical, psychosocial, and other pertinent data obtained from patient or caregiver
Objective data: anthropometric measures, lab values, and other clinical findings
Assessment: Nutrition diagnosis based on subjective and objective data; stated as nutrition “problem” related to
“etiology” as evidenced by” signs and symptoms” (PES statement)
Plan: Intervention using standardized language that helps change or resolve the nutrition problem; includes food or
nutrient delivery, nutrition education, nutrition counseling, and coordination of care

Example of SOAP Chart Note:

S: Pt lives alone and reports frequent intake of snack foods since death of her husband six months ago. States she
was diagnosed with type 2 diabetes right before her husband became ill one year ago. Reports recent weight gain of
10 pounds since starting on antidepressant medications four months ago.
O: 78 yo female, Ht 64 inches, Wt 162 pounds, BMI 27.8, A1C 7.9, random blood glucose 183; 24-hour diet recall
reveals intake of 2300 kcalories, 102 grams fat, 250 grams carbohydrate, and 95 grams protein.
A: Excessive energy intake related to recent life stressors and medications that increase appetite as evidenced by
weight gain, BMI greater than 25, blood glucose and A1C above recommended target goals.
P: Motivational interviewing to assist patient in making changes in food-related behaviors. Referral to medical
social worker for grief counseling resources.

ADIME Format (from American Dietetic Association Nutrition, Diagnosis and Intervention: Standardized
Language for the Nutrition Care Process, 2007 and International Dietetics & Nutrition Terminology (IDNT)
Reference Manual, 2008)
Assessment: Relevant data used to determine whether a nutrition diagnosis/problem exists; includes pertinent
medical and psychosocial history, anthropometric, and lab data.
Diagnosis: Identifies the specific nutrition problem (diagnosis) that can be resolved or improved through nutrition
intervention. Documented in a “PES” statement: “problem” related to “etiology” as evidenced by “signs and
symptoms.” Uses standardized language and addresses at least one of three nutrition diagnoses categories: Intake,
Clinical, or Behavioral-Environmental.
Intervention: Specific treatment goals to resolve or improve the identified nutrition problem. Includes appropriate
interventions tailored to the patient’s/client’s needs.
Monitoring and Evaluation: Determines the amount of progress made and if goals or expected outcomes are being
met. Includes monitoring, measuring, and evaluating changes in patient’s behavior, nutritional status, or other
indicators of nutrition care and plans for future nutrition care.

Example of ADIME Chart Note:

A: 78 yo female, diagnosed with type 2 diabetes one year ago. Ht: 64 inches, Wt: 162 pounds, BMI 27.8, A1C 7.9,
random blood glucose 183. Pt lives alone and reports frequent intake of snack foods since death of her husband six
months ago. Reports recent weight gain of 10 pounds since starting on antidepressant medications four months ago.
24-hour diet recall reveals intake of 2300 kcalories, 102 grams fat, 250 grams carbohydrate, and 95 grams protein.
D: Excessive energy intake related to recent life stressors and medications that increase appetite as evidenced by
weight gain, BMI greater than 25, blood glucose and A1C above recommended target goals.
I: Motivational interviewing to assist patient in making changes in food-related behaviors. Referral to medical social
worker for grief counseling resources.
M/E: Pt states she has not participated in diabetes self-care management classes and rates herself a 2 on a scale of 1-
10 on her ability to choose a healthful diet to control her diabetes and weight. Pt set goal to participate in hospital-
sponsored diabetes education classes within the next month. Will evaluate progress at next visit.

© 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
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Livesey, L.-Sgt. C. E.
Longson, Pte. J.
Loughlin, Pte. E.
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People, Pte. T. A.
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1/6 BATTALION MANCHESTER REGIMENT

Officers

Holberton, Lt.-Col. P. V.
Worthington, Lt.-Col. C. S., D.S.O.
Davies, Lt.-Col. O. St. L.
Heywood, Maj. A. G. P.
Bazley, Capt. W. N.
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Jackson, Capt. S. F.
Kessler, Capt. E.
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Waine, Capt. W. H.
Walker, Capt. A. J.
Brook Taylor, Lieut. A. C.
Donald, Lieut. A. J.
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Mills, Lieut. T. R.
Thorburn, Lieut. E. F.
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Compton Smith, 2nd Lieut. R.
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Dick, Pte. H.
Dobson, Pte. L.
Dodd, Pte. W. N.
Doig, Pte. A. M.
Duggins, Pte. M.
Duke, Pte. W.
Dunbar, Pte. H.
Dunkerley, Pte. J.
Dyer, Pte. J.
Dyson, Pte. C.
Earle, Pte. J.
Eckersley, Pte. T.
Edwards, L.-Cpl. F.
Edwards, Pte. J. G.
Egerton, Pte. J. W.
Ellis, Sgt. W.
Elton, Pte. J. F.
Evans, Pte. G.
Evans, Pte. L.
Evans, Pte. W.
Evanson, Pte. W.
Fagan, Sgt. T.
Fairy, Pte. W.
Fancourt, Pte. L. C.
Felton, Pte. N.
Ferguson, Pte. A.
Ferguson, Pte. D.
Few, Cpl. H. A.