ADIME Chart Note for Dietetics Case Study

The attached ADIME template needs to be filled out with appropriate information and medical abbreviations. All the correct information is given but experience is needed to fill out the note for the case study information. The budget is not higher because I have all the correct information. I just need a tutor with medical and dietetics experience to fill out the chart note with the correct information.

ADIME Format
Your note
A
Example Delete this row and column when turning in your final note
CH
77 y/o male adm ć stage III decub. Hx of depression on MAOI. Pt
lives alone ć son visiting once per month. Pt c/o poor appetite.
Denies N/V/D/C
Meds: Nardil (phenelzine)
AD
Ht: 5’10” Wt: 145# (Per chart) UBW 153# (1 month) 95% UBW
IBW: 166# + 10% (149-183#) IBW % 97% LL BMI 20.8 ↔
COMMENTS
 Use this column as a check to make sure you have
all the data you need.
 Delete this column when turning in your final note
 Convert to Portrait Layout to turn in
 Remove all the lines- home-paragraph tab-no
borders- see final page below
 Put new topic on new line ex. anthropometrics,
labs, meds etc.
Clinical Hx:
 age/FM/dx/PMH/treatment
 Nutr: c/o such as N/V/D/C, I/Os
 social hx
 Meds: Pertinent meds (do not need dose)
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Anthropometric data:
Indicate Wt per RN, per pt, per chart with timing
IBW % ↑/ ↓WNL/ ↔
If pt’s wt is within the range then put WNL or use LL
if pt’s wt is low or UL if above the range
UBW must have timing of wt ∆
BMI: Include normal overwt/obese etc.
Nutrition Focused Physical Findings
Phys appear/muscle/ wasting/dentition
swallow/appetite/NFPE see ASPEN/AND guidelines
Food Hx:
PO Intake kcal/pro/fat/fiber/fluid/
and/or TPN/EN intake (kcals, pro, fluid provided)
Diet hx/env
Diet order (per chart) or MD diet order
Knowledge/belief/attitude/motivation/behavior/PA/
mobility
Access
Food drug interactions
Kcal, pro, and fluid needs (include factors used)
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Include ↓↑↔ on all labs
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NPF
FH
BD
Pt has poor dentition and unable to chew regular diet especially
meats. Overall thin appearance, sunken orbitals, slight depression of
temples
Diet hx: Pts diet PTA inadequate in Kcals and protein. Pt states he
has been too tired to eat and appetite is poor for 2 weeks. Eating < 50% for 2 weeks. Pt states he has been unable to chew meats so has been eating cheese. Pt unaware that cheddar cheese contraindicated with MAOI. Son visits once per month. Provides some assistance with meals. Diet order: Regular (date) -MD ordered diet PO intake 25% of meals per nursing Potential Food Drug interaction: Pt consumes cheddar cheese while on Nardil MAOI Estimated needs: 2300 kcals (35kcals/kg), 86-105g pro (1.3-1.6g/kg); fluid: 2300ml (1 ml/kcal) Labs: Glu 90mg/dL↔ , Alb 2.8 mg/dL↓       D 1. Severe malnutrition related to poor PO intake as evidenced by physical exam findings consistent with fat and muscle wastingtemporal wasting and sunken orbitals, and 5% wt loss in past month, and < 50% PO intake > 14 days
2
or. …Inadequate caloric and protein Intake R/T
Increased requirements for wound healing, poor appetite, and poor
dentition AEB 5% Wt loss in 1 month, alb 2.8mg/dL ↓, Stage III
decub, and PO intake < 50% x 1 month  List all appropriate labs for THIS case ć mg/dL Alb, Glu, HA1C, Chol, HDL/LDL, TG, H/H MCV, K, Na, P, ABGs, Other  If using malnutrition as dx- see ASPEN/AND Guidelines    3. FND If comparing intake to recommended use a percentage for clarity for the MD Potential Food Drug interaction related to knowledge deficit of contraindicated food and Meds as evidenced by pt’s intake of cheddar cheese while on Rx Nardil INTERVENTION I PES: Problem related to the Etiology as evidenced by S&S (measurable Signs and Sx) Make sure it is a true cause and something that you can do something about. Preferably the intake domain per the Academy YOUR “S” should be able to be “copied” to your M/E- this will be a way that you can tell if you made a difference with your intervention. 1. 2. 3. 4. 5. 6. Recommend diet change to Mechanical Soft diet Will provide high kcal and protein snack between meals Provide high protein, high kcal foods per pt preference No high tyramine foods Recommend Calorie Count to monitor PO intake Recommend Commercial beverage (Ensure BID) if no improvement in PO intake in 2 days KEY POINT: YOUR INTERVENTIONS ADDRESS YOUR “E” OF YOUR PES STATEMENTS ABOVE Do not put an intervention for a problem you have not identified- go back and make a PES if you need to. If you listed a problem- you must have an intervention for it—either FND, NE, CC USE WHEN: Pt is in hospital and you want the MD to change the diet in some way or you plan to adjust the diet in some way that does not need MD approval. Meal distribution- what FS dept. will provide while in hospital • Provide __________diet (as ordered) • Recommend Diet order change to _______ (if needed) • Will provide ↑or ↓protein/kcal/snacks/fiber/fluid/ • Recommend Commercial Beverage (ex. Ensure BID/TID) if needed NE 1. Educated pt and son and encouraged high Kcal and pro meals and snacks 2. Educate pt and son on high tyramine foods to avoid while on Nardil USE WHEN: You have a brief education time - pt is in acute care/hospital- Pick NE or NC, but not both. If you think pt should talk to their doc about med changesput it in your med note here Do not put pt and family if not appropriate for THIS pt. • Educated pt/family on _________diet • Educated pt /family on importance of_________ • Encouraged ___________ • Leave details of diet out of medical note ie what constitutes a high fiber diet. USE WHEN: You have ongoing counseling with pt. Usually at least 30 min and outside of hospital setting. Use for outpt counseling NC • • CC Refer to SW for Meals on wheels referral ṕ discharge Do not refer to the MD already on the case Do not refer to pharmacy regarding a med if you can talk to the pt about it. Nutritional Counseling  Usually reserved for ongoing counseling session – outpatient. Leave out of not using it. USE WHEN: You want to make a referral to someone out of your field such as SW, SLP • • • • M/E 1. Prevent further wt loss Pt to consume 75% of meals/snacks through hospital stay Who do you refer to? Areas out of your expertise or after discharge Refer to SW for MOW/any discharge assistance/access Refer to SLP for swallowing eval Do not refer to pharmacist for food drug intx- you take care of it Look at "S" of PES list values with timing of improvement must be measurable- put a number on it if you can. Includes wt changes, lab values. Can also include sx resolving or lack of sx. MUST BE SOMETHING YOU OR MD WILL BE ABLE TO CHECK ON. DO NOT PUT PT’s FOOD RECORD WILL SHOW…… for acute settings. (can use for counseling) 2. 3. 4. Healing of decub; diarrhea will resolve, No sx of__________ Alb to trend WNL through hospital stay/or by next MD office visit Pt to discontinue intake of ____(food) while on Rx__________ © Copyright. Samantha Davis, 2023. This work is licensed under a Creative Commons Attribution-Non-Commercial-No Derivatives 4.0 International License. Your actual ADIME note will be diminished to these areas listed below. Add as many points as needed. Convert to portrait layout to turn in. A: D: 1. 2. 3. I: FND NE NC CC M/E: 1. 2. 3. Assessment Information (Include: hemoglobin, hematocrit, MCV) IBW = 140# +/-10% 105.7% IBW 2.6% weight loss in one year hasn’t been formally diagnosed with anything!! BMI = 22.6 indicative of healthy weight for height Est kcal intake = 1735 kcal/day Est protein intake = 68 g protein/day Use 26-27 kcal/kg/day to estimate kcal needs; Use 1.1-1.2 g protein/kg/day to estimate protein needs; Use 35 mL/kg to estimate fluid needs Mifflin St. Jeor – 1461 kcal/day MCV = 71.4 MCH = 23.8 MCHC = 33.3 g/dL Lab values indicate microcytic anemia Vitamin B12 intake sufficient Vitamin C intake mildly insufficient Iron intake insufficient PES Statements Inadequate mineral intake of iron related to food and nutrition knowledge deficit re: vegan diet as evidenced by Hgb =10 g/dL, pallor of face, fatigue, no intake of heme iron and low intake of non-heme iron per food recall. Increased iron needs related to increased blood loss secondary to heavy periods and decreased iron absorption due to high intake of polyphenols from tea and consuming vegan diet as evidenced by biochemical (Hgb =10 g/dL, Hct=32%, MCV=71.4 μm3, MCH=23.8 pg, MCHC=33.3%) and clinical evidence of iron deficiency (pallor and fatigue). Diagnosis: 1. Inadequate mineral intake of iron related to food and nutrition knowledge deficit re: vegan diet as evidenced by Hgb =10 g/dL, pallor of face, fatigue, no intake of heme iron and low intake of non-heme iron per food recall. 2. Increased iron needs related to increased blood loss secondary to heavy periods and decreased iron absorption due to high intake of polyphenols from tea and consuming vegan diet as evidenced by biochemical (Hgb =10 g/dL, Hct=32%, MCV=71.4 μm3, MCH=23.8 pg, MCHC=33.3%) and clinical evidence of iron deficiency (pallor and fatigue). Intervention: ● Nutrition Education re: iron rich food options appropriate in vegan diet, increased iron needs of 1.8 times non-vegan diet for those following vegan diet, role of foods/beverages that impact absorption (vitamin C, tannins, and phytates), iron supplement information and timing of iron intake through foods/supplements, and management of possible constipation (increased fluid/fiber/activity) resulting from iron supplementation. Discussed other potential nutrients of concern with vegan diet (Vitamin B12, Calcium, Vitamin D, Zinc, Omega 3 fatty acids) and food sources. ● Coordination and Referral of Nutrition Care with physician to provide therapeutic Fe Rx and follow-up appointment to monitor status of laboratory values ● Coordination and Referral of Care: Pt to follow-up with either PCP or gynecologist to address heavy menstrual periods. Goals: ● Pt will consume at least four servings of iron rich foods daily combined at the same time with one serving of vitamin C rich food/beverage (both from provided list) as logged in food diary for next month. ● Pt will decrease coffee and tea intake to a total of < two 8 oz cups of coffee daily within two weeks per food diary. ● Pt will take 45 mg of over the counter ferrous sulfate or ferrous gluconate with ½ cup orange juice and on an empty stomach daily until a prescription for higher dose iron is obtained. Monitoring and Evaluation 1. Pt to maintain a food diary and bring to f/u appointment in one month. RD will review/monitor food intake including Vitamin C and iron containing foods and total caffeine intake (tea/coffee) at that time. 2. Review overall iron intake from dietary supplement/iron Rx and foods (per food diary). 3. Monitor Nutrition Anemia Profile (Hbg, Hct, MCV, TIBC, Serum Ferritin, Serum Iron, TSAT). Recommend labs run ~ 5-7 days before appointment. Objectives: • Use current information technologies to locate and apply evidence-based guidelines and protocols, such as the Evidence Analysis Library. • Describe the governance of nutrition and dietetics practice, such as the Scope of Practice for the Registered Dietitian Nutritionist and the Code of Ethics for the Profession of Nutrition and Dietetics. (KRDN 2.2) • Utilize the Nutrition Care Process. • Demonstrate documentation that follows professional guidelines. Ms. Espinoza is a 26 YO Hispanic female. She is a graduate student at TCU and works as a graduate assistant in the English Department. She presented to the Student Health Center after feeling weak and lethargic for the past few months. Prior to the visit, patient reports fatigue for the past two or more months and worsening in the last two weeks. Ms. Espinoza is a vegan and has been for about one year. Her weight has been stable for the past year. Prior to that time, her weight was approximately 152#. She initially chose a vegan lifestyle for environmental and animal rights purposes. She has become more committed to the lifestyle for health reasons over the past two years. She reports that her appetite is fine. She does not consume any meat, poultry, fish, milk or eggs. She consumes legumes regularly, drinks plain soy milk, and eats soybeans and tofu regularly. She usually consumes legumes meals and also tries to eat a whole grain at the same time. She does not take any medications or dietary supplements. She has no food allergies or intolerances. She reports heavy menstrual periods. Medical Hx: menarche age 14 Social Hx: Lives in an off-campus apartment alone; Denies tobacco or illicit drug use; Does not consume alcohol or drugs; Sedentary lifestyle with infrequent exercise. She walks about one mile (round trip) from her off-campus apartment to campus on weekdays. She takes the stairs to her four-story office on campus and her two-story apartment off-campus. Otherwise, she rarely exercises. Symptoms: Dizziness, Pallor, Pale gums, Fatigue, Easily fatigued upon physical activity Medications/Supplement: none Ht: 5’8”. Wt: 148#. Patient’s lab values are as follows: Test Glucose BUN Cr Ca Serum Albumin RBC Result 85 mg/dL 12 mg/dL 0.7 mg/dL 8.8 mg/dL 3.7 g/dL 4.2 Reference Value 70-110 mg/dL 10-20 mg/dL 0.5-1.1 mg/dL 9.0-10.5 mg/dL 3.5-5.0 g/dL 4.2-5.4 WBC 76000/mm3 5000-10000/mm3 Test Na K Cl Hgb Hct Platelets Result 142 mEq/L 4.0 mEq/L 102 mEq/L 10.0 g/dl 30% 270,000/mm3 Reference Value 136-145 mEq/L 3.5-5.0 mEq/L 98-106 mEq/L 12-16 g/dl 37%-47% 150.000400,000/mm3 You are an outpatient RD consulting at the student health care center. You received a consult to assess the patient due to her reports of fatigue and to provide nutrition education regarding a general, healthy diet. She says that she feels tired and finds it necessary to take a nap almost every evening after she leaves work before she begins studying. She drinks 2-4 cups of black tea daily to try to stay awake and alert. She states that she has struggled academically this semester and thinks that her fatigue is to blame. You obtain a 24 hour recall from the patient. She reports that he usually eats alone. She does not take any dietary supplements. This menu is fairly representative of her usual intake. Besides the beverages listed in her recall, Ms. Espinoza drinks water throughout the day. Breakfast: 2 6 oz cups of black tea ½ cup raw oats 1 T peanut butter 1 cup Silk Original Soymilk* ½ cup blueberries 1 T pumpkin seeds Lunch: 3 cups of baby spinach ½ cup canned Kroger salted garbanzo beans 1 cup raw broccoli florets 8 Mezzetta pitted Greek Kalmata olives* 20 Wheat Thins* (crackers) 1 8 oz cup black tea Snack: ½ large banana 1 oz Kroger dry roasted peanuts* 2 6 oz cups of black tea Dinner: Tofu tacos (2 Mission corn tortillas*, 3 oz Trader Joe’s Firm Tofu* cooked in 2 tsp olive oil) 2 tsp soy sauce ½ cup canned salted black beans 1 cup butter lettuce 4 Tablespoons of avocado water Snack: 1 cup Silk Original Soymilk* ¼ cup blueberries water * find precise information for these items rather than using estimates on the exchange list in your Nelms textbook. Documentation Medical Record • Systematic recording of a patient’s care • Location where all data related to medical problem is collected • LEGAL document Need to be thorough on documentation to validate and record all things done with patient Everything is under HIPPA in the file (can bounce ideas Purposes • Legal documentation of medical care that the client has received. • Document communication between members of the health care team. • Determine patient care • Evaluation of medical care for that client. • Funding & resource management. • Continuous quality improvement. • Third party reimbursement. • Accreditation. • Monitor, evaluate and improve pt care. • Research. • Broader picture helps evaluate what needs to happen • Determines for staffing and funding Terms • Current Procedural Terminology (CPT codes) – Numeric codes used to describe a medical service; these codes were developed by the American Medical Association with the Health Care Financing Administration • Medicare bad reimbursement rates • Prospective Payment System: – System developed by the US government to reimburse health care providers for inpatient health services at a predetermined rate for a particular diagnosis and level of care How is the information documented? Using standard language & medical abbreviations https://www.tabers.com/tabersonline/view/Taber s-Dictionary/767492/all/Medical_Abbreviations • Use standardized terms Unacceptable abbreviations https://www.jointcommission.org/facts_about_do_not_use_list/ • U (unit) • IU (International unit) • QD, qd (daily) • QOD, qod (every other day) • Trailing zero (2.0 mg) • Lack of leading zero (.3 mg) • MS, MSO4, MgSO4 Written Abbreviation Notes • No @; write out at; can be mistaken for the number 2. • No > or