ADIME is a useful starting point when you want your note to follow the Nutrition Care Process. SOAP can also work when your charting system or care team uses that structure. The goal is to make your nutrition reasoning clear in the record your practice uses.
The Academy of Nutrition and Dietetics explains that the Nutrition Care Process can be used in any documentation system. ADI and ADIME follow its steps directly. Choosing different headings does not mean abandoning the process. See the Academy’s overview.
What changes between ADIME and SOAP?
ADIME organizes a note around Assessment, Diagnosis, Intervention, and Monitoring and Evaluation. SOAP uses Subjective, Objective, Assessment, and Plan. UMass Dartmouth’s clinical-note guidance explains the SOAP structure.
The two Assessment sections do different jobs. ADIME’s nutrition assessment gathers the information used to identify a nutrition problem, including interview material, measurements, and records. In SOAP, that information is distributed across Subjective and Objective; Assessment contains the clinician’s interpretation. Changing the headings alone is not enough. The Academy’s nutrition-assessment guidance describes the scope of that first step.
Which format fits your practice?
Start with your required chart structure and the needs of the people receiving the note.
- Consider ADIME when you control the format and want each Nutrition Care Process step visible under its own heading.
- Consider SOAP when it is the established chart structure or the format requested for care coordination. Decide where your nutrition diagnosis, completed interventions, and follow-up will appear.
- Add focused prompts when needed. A template can retain required headings while giving you a clear place for important information, without repeating the encounter in several sections.
These are practical suggestions, not payer rules. Neither acronym alone establishes that a note is complete or meets a particular documentation requirement.
Blank outlines to compare
Use these outlines to evaluate a format. They are editorial starting points, not official Academy templates or complete lists of required record fields. Add the identifying, encounter, and authentication information your record requires.
ADIME outline
- Assessment: [Relevant nutrition history and assessment data; sources and dates where needed; information to clarify]
- Diagnosis: [Clinician-established nutrition diagnosis and supporting PES statement, when applicable]
- Intervention: [Interventions delivered; agreed goals; planned actions, distinguished from completed care]
- Monitoring and Evaluation: [Indicators and comparison criteria; progress evaluated today; what will be reassessed and when]
Monitoring and evaluation involves assessing progress against selected indicators and criteria. Include both what you will track and how you will judge change. Read the Academy’s guidance.
SOAP outline for a nutrition visit
- Subjective: [Relevant patient-reported information, with the source clear]
- Objective: [Measured or observed findings and available record data, with dates and sources where needed]
- Assessment: [Your interpretation; nutrition diagnosis and supporting reasoning; evaluation of progress when applicable]
- Plan: [Next actions; agreed goals; monitoring and follow-up]
Add a clearly labeled place for interventions delivered during the visit, consistent with your charting conventions. Keep completed care distinct from future plans. This is one possible adaptation of SOAP for nutrition documentation, not an official one-to-one conversion.
Where does the PES statement go?
PES stands for Problem, Etiology, and Signs and Symptoms. The Academy describes it as the structured statement used to communicate a nutrition diagnosis. See its nutrition-diagnosis guidance.
In these outlines, PES sits in Diagnosis for ADIME and Assessment for SOAP. Its placement changes; the supporting reasoning still needs to be clear. A template should leave room for your conclusion without prompting an unsupported diagnosis or cause.
Check the format before adopting it
- Destination: Do the headings and required fields work in the chart where the note will be kept?
- Sources: Can you distinguish patient reports, measurements, records, and your interpretation?
- Reasoning: Can you find the nutrition diagnosis and its supporting evidence?
- Timeline: Is completed care separate from future plans?
- Follow-up: Are goals, indicators to review, and outstanding information easy to find?
- Usability: Are prompts redundant, and does required information survive copying into your chart?
If you use an AI scribe, apply the same checks to its draft. Review factual accuracy, omissions, source attribution, and whether it reflects your clinical reasoning before finalizing it.
Using Medical Scribe with your chosen format
Medical Scribe offers an ADIME-structured Dietitian’s Note, alongside SOAP and custom formats. Choose a structure that fits your workflow, then review and edit the draft before adding it to your record.
Explore Medical Scribe for dietitians and use the checklist above to evaluate the format for your practice.