SOAP Notes for Nutritionists: Format, Examples, and When to Use ADIME Instead

Most nutritionists learned SOAP notes because that's what every other healthcare provider around them uses, not because it was built for nutrition work. There's a format that actually was: ADIME. Here's what each one looks like, a real example of both, and when switching is actually worth it.

Where each format came from

SOAP was never built for nutrition. Physician Lawrence Weed introduced it in the 1960s as a general clinical documentation format, and it spread across medicine, physical therapy, mental health, and most allied-health disciplines because it gives any provider on a case a shared structure, regardless of specialty.

ADIME came later and from a different direction. The Academy of Nutrition and Dietetics built it specifically for dietetics, as part of a broader framework called the Nutrition Care Process. It borrows SOAP's general shape but adds something SOAP was never designed to hold: a dedicated step for nutrition-specific clinical reasoning.

SOAP notes: structure and example

SOAP has four sections.

Subjective is what the client reports in their own words, symptoms, adherence, how they've been feeling.

Objective is measurable data: weight, labs, vitals, intake logs.

Assessment is the practitioner's clinical interpretation, connecting subjective and objective findings.

Plan is the concrete next step.

The following is a fictional, illustrative example only, not a real client record:

Subjective: Client reports fatigue and increased urination over the past two weeks.

Objective: Weight 85kg, blood pressure 130/85 mmHg, HbA1c 8.2%.

Assessment: Symptoms and labs consistent with poor glycaemic control.

Plan: Shift meal plan toward lower-GI foods, increase daily activity, follow up in 4 weeks.

Notice what SOAP doesn't ask you to do anywhere in that structure: name why the problem exists in nutrition terms, or link it to a specific, documented cause. That's exactly the gap ADIME was built to close.

ADIME: structure and example

ADIME has five steps:

Assessment (diet history, labs, anthropometrics. The raw data).

Diagnosis (a structured nutrition diagnosis, explained below).

Intervention (the actual nutrition care plan).

Monitoring/Evaluation (tracking progress against that plan over time).

The Diagnosis step is the one with no SOAP equivalent, and it's built around something called a PES statement: Problem, Etiology, Signs/symptoms. It forces you to name the nutrition problem precisely, state why it's happening, and back both with evidence, in one sentence, every time. A PES statement can also stand on its own, separate from a full ADIME note, useful for an initial screening or a brief consultation, before you've decided whether the case warrants the full structure.

The Intervention step isn't just "the plan" in general terms. In the Nutrition Care Process, interventions fall into named categories worth knowing: nutrition prescription (a specific target, like a calorie or macro adjustment), food or nutrient delivery (concrete changes to what's eaten), education, coordination of care (referrals to other providers), and SMART goals tying the plan to a measurable timeframe. A strong Intervention entry usually touches at least two of these, not just one vague sentence.

The following is a fictional, illustrative example only, not a real client record, using the same scenario as above so you can compare the two formats directly:

Assessment: Diet history shows frequent intake of sugary snacks and refined carbohydrates; labs show elevated HbA1c.

Diagnosis (PES statement): Excessive carbohydrate intake (Problem) related to lack of nutrition education (Etiology) as evidenced by HbA1c of 8.2% and reported frequent urination (Signs/symptoms).

Intervention: Nutrition prescription: reduce daily carbohydrate intake by roughly 30g. Education: carbohydrate-counting session and lower-GI food swaps. Coordination of care: referral to GP for glycaemic monitoring.

Monitoring/Evaluation: Re-check HbA1c and energy levels; follow up in 4 weeks.

Same client, same underlying facts as the SOAP example above. The difference is that the ADIME version makes the why explicit and checkable, instead of leaving it implied inside a paragraph of assessment prose.

You can copy-paste this example into Notrispace to use in your sessions with scribe:

ADIME Note Template

Assessment
[Anthropometrics: weight, height, BMI, recent weight change]
[Relevant medical history: diagnoses, medications, lab results]
[Diet history and current intake pattern]
[Lifestyle factors: activity level, sleep, stress, relevant psychosocial context]

Diagnosis
Problem: [the nutrition problem, named precisely]
Etiology: [why it's happening — the cause, not just the symptom]
Signs/Symptoms: [the evidence — labs, reported symptoms, measurable data]
(Combine as one PES sentence: "[Problem] related to [Etiology] as evidenced by [Signs/Symptoms].")

Intervention
Nutrition prescription: [specific target — calorie, macro, or nutrient adjustment]
Food/nutrient delivery: [concrete dietary changes]
Education: [what was taught or discussed this session]
Coordination of care: [any referrals or provider communication]
Goal: [one SMART goal — specific, measurable, with a timeframe]

Monitoring/Evaluation
[What will be tracked: weight, labs, symptoms, adherence]
[Follow-up timing]
[Reassessment criteria — what would trigger a change in plan]

When to use which

In multidisciplinary or hospital-adjacent settings, SOAP usually wins on practicality. Every provider on the case already knows it, so it keeps communication simple across a team that isn't nutrition-specific. That cuts both ways: an ADIME note sent to a GP or a physiotherapist outside dietetics may not be immediately legible to them, since the structure isn't one they're trained on. In dedicated clinical dietetics settings, ADIME is generally preferred precisely because of that Diagnosis step: it documents nutrition-specific reasoning in a way a generic format can't.

In practice, though, plenty of independent practitioners use whichever format their software happens to offer, rather than choosing deliberately based on their setting. That's worth noticing in your own practice: are you using SOAP because it's genuinely the better fit, or because it's the only template your tool gives you?

Where Notrispace fits today

Notrispace's Scribe drafts notes in either SOAP or ADIME format and you can edit them yourself. it's a template choice, not a different tool, so you're not locked into one structure across your whole practice. Choose whichever fits the session or the setting, and Scribe drafts within that structure from your transcript, PES statement included when ADIME is selected. Every draft goes through your review before it's saved, regardless of which template you're using.

That also means the "when to use which" question above isn't a compromise you have to make with your software. A multidisciplinary referral note can go out in SOAP; the same client's ongoing dietetic record can stay in ADIME. See our AI assistant for nutritionists for how Scribe handles the rest of the documentation workflow around it.