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Standardized Language Analysis

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The nutrition care process provides a framework for individualized and high quality care (cite) with the intention to guide nutrition professionals. Included in the nutrition care process, is the use of standardized language. Standardized language is important because it enables clear documentation of the impact and process of patient care. In addition, it also demonstrates the role of the dietetics professional while also ensuring that people can clearly articulate the nutrition problem and describe the interventions, goals and approaches that were executed. Standardized language enables a greater understanding of the connection between the nutrition problems, interventions and outcomes. ADIME is an acynym that stands for assessment, diagnosis, intervention, monitoring and evaluation. ADIME manifests the use of …show more content…

During the initial appointment it is imperative to gather information and make sure that the session is client focused. Information needed to gather during the initial appointment include: reason for counseling, past counseling, current diet including alcohol, living condition, diet history. This information is important because it helps dietitians accurately assess the patient and the initial goal-setting process. It also helps the dietitian and patient evaluate what worked and what did not work and how to successfully achieve their goal. In addition, the information gathered during the initial appointment will allow the RD to calculate energy needs, analyze their diet and complete their ADIME note. Without properly assessing and gathering the information from the initial appointment, adequate documentation may be lacking in addition to inadequate tracking of the patient’s goals and overall

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