How to read a patient chart like a pro: Adapting a chart into a strong nutrition note

A well-written nutrition note reflects more than just documentation of what has already been written elsewhere in the chart. It should be a combination of reasoning, prioritization, and clinical judgment of the dietitian based on the information they collect.  

After learning where to find necessary information in the medical record, how does a dietitian build confidence in interpreting that information and translating it into a clear assessment, accurate nutrition diagnosis, and meaningful plan of care?   

Clinical notes that simply list labs, weight data, and diagnosis often feel like a repeat of what has already been stated. In contrast, strong clinical notes take the data already available and connect it with the Nutrition Care Process. This really shows the value of a dietitian as an integral part of the healthcare team.  

This blog post provides a practical framework to help dietitians strengthen how to use information from the patient’s chart to: 

1. Create a strong nutrition assessment 
2. Write clear and meaningful PES statements  
3. Develop patient-centered interventions 
4. Build solid care plans with clinical intent 

Reading the chart through a clinical lens 

The Academy of Nutrition and Dietetics describes the Nutrition Care Process (NCP) as a systematic method designed to provide high-quality, individualized nutrition care through four interconnected steps: assessment, diagnosis, intervention, and monitoring/evaluation.  

Instead of attempting to use every available piece of data, start by identifying the information that directly supports each step of the NCP and apply it to make a strong assessment, diagnosis, and care plan. Then follow a step-by-step workflow to stay organized, instead of overwhelmed. 

Step 1: Determine the situation 

Start with the reason for the nutrition assessment, such as the reason for consultation, the result of the nutrition screening, or a significant change, and the reason the patient is receiving care in the first place. Look at their admitting diagnosis. Is this an acute problem or something more chronic? Are they clinically stable, or is their condition worsening? Consider all relevant comorbidities that influence their nutritional status.  

Step 2: Gather specific data needed for the nutrition assessment 

Remember, if the information doesn’t change the plan, it probably doesn’t belong. Focus on the following: 

• Oral (PO) Intake and Tolerance – Percentage of intake, GI symptoms (nausea, vomiting, diarrhea, constipation, etc.), early satiety, loss of appetite 
• Weight History – Usual body weight, any recent weight gain or loss, fluid shifts 
• Functional Factors – Ability to self-feed, dentition, cognition, need for modified textures 
• Medical Factors – Procedures that affect nutrition, presence of a wound or skin breakdown, dialysis, infection, inflammation 
• Pertinent Lab Data – Only if it relates to your problem, outline trends if able 

Step 3: Identify the nutrition problem 

Most patient charts will contain multiple medical diagnoses. It’s the dietitian’s goal to determine the nutrition problem that is most clinically relevant and that can be addressed with nutrition intervention(s).

Step 4: Write a strong PES Statement

• Problem – The nutrition diagnosis 
• Etiology – The cause 
• Signs and Symptoms – Evidence found in the chart 

An example might look like: Inadequate energy intake related to poor appetite and early satiety as evidenced by <50% PO intake for the last 5 days and 6% unintentional weight loss over the last 2 months.  

Step 5: Develop strong nutrition interventions

Consider diet order vs actual intake and swallow safety vs texture restrictions. Are their current treatments impacting their PO intake?  Don’t forget to question things like pain, nausea, medications, and medical procedures. What is their discharge plan and their education readiness? Are there any barriers, such as food access, limited support at home, impaired cognition, or lack of motivation?  

Step 6: Create and evaluate a plan of care

Monitoring and evaluating the plan should not feel like an afterthought in the nutrition note. This is where clinical intent really comes to life. When developing a plan of care, return to the original nutrition problem and question what the expected change is. 

An effective plan of care is specific, measurable, and clearly connected to the assessment and nutrition diagnosis. It helps the interdisciplinary team understand what the dietitian is following and why it matters. It also guides follow-ups and allows for adjustments based on meaningful outcomes, rather than just routine check-ins.  

A practical example: Reading the chart like a pro 

To illustrate how this process works in clinical practice, consider the following: 

Information found during chart review: 

• 72-year-old female admitted with pneumonia  
• Past medical history includes heart failure (HF), chronic obstructive pulmonary disease (COPD), and type 2 diabetes 
• Poor appetite documented in nursing notes 
• Meal percentages range 25-50% of meals for the past 4 days 
• Weight – 160 lbs today; 170 lbs one month ago (6% loss) 
• Speech language pathologist (SLP) note states mild dysphagia present, and soft and bite-sized foods are recommended 
• Patient reports feeling short of breath while eating 
• Blood glucose ranging 140-220mg/dL 
• Patient lives alone with limited support at home 

Applying ADIME format (Assessment, Diagnosis, Intervention, Monitoring/Evaluation): 

After gleaning the most relevant information from the chart and conducting an interview with the patient, the following ADIME note was written.  

Assessment 

A 72-year-old female was admitted with pneumonia and a past medical history of HF, type 2 diabetes, and COPD. Her appetite is poor, and she becomes fatigued with meals documented by nursing; she consumes approximately 25-50% of meals over the past 4 days. She reports shortness of breath during meals. A 6% weight loss over one month is noted. SLP evaluation indicates mild dysphagia with recommendation for a soft and bite-sized diet, which may further limit intake. Patient lives alone with limited support, which may impact nutrition management after discharge.  

Diagnosis (PES Statement) 

Inadequate energy intake related to poor appetite and dyspnea with meals in the setting of acute illness as evidenced by 25-50% PO intake over 4 days. 

Interventions 

• Recommend a high-calorie, high-protein diet consistent with SLP recommendations for texture modification 
• Initiate oral nutrition supplement twice daily between meals (patient prefers vanilla flavor) 
• Encourage small, frequent meals to reduce fatigue while eating 
• Coordinate with nursing to provide and document the percentage taken of supplements 
• Provide brief nutrition education as tolerated 

Monitoring/Evaluation 

Monitor PO intake trends, supplement acceptance, weight changes, and tolerance to the modified texture diet. Reassess nutrition plan if intake remains <50% over the next 48-72 hours. Follow up prior to discharge to reassess nutritional needs and provide additional education as needed. 

Bringing it all together 

Reading the patient’s chart like a pro means focusing on what actually matters rather than trying to capture everything and repeat what’s already been stated. When approaching the chart this way, nutrition notes become clearer, and dietitians’ care plans more meaningful. This takes practice, but having a structured approach makes it easier over time. Consider this step-by-step process to streamline an initial assessment and develop a measurable plan. When the plan of care is clear and specific, the interdisciplinary team may be more likely to implement it consistently, which could lead to better patient outcomes.  

---

Dietitians On Demand is a nationwide staffing and recruiting company for registered dietitians, specializing in short-term, temporary, and permanent-hire positions in acute care, long-term care, and food service. We’re dedicated to dietitians and helping them enhance their practice and excel in the workplace. Check out our job openings, request your coverage, or visit our store today!

---

References:  

Nutrition Care Process Overview. EatRightPro website. Accessed January 25, 2026. https://www.eatrightpro.org/practice/nutrition-care-process/ncp-overview.  

Nutrition Diagnosis. EatRightPro website. Accessed January 25, 2026.  https://www.eatrightpro.org/practice/nutrition-care-process/ncp-overview/nutrition-diagnosis. 

Lewis SL, Miranda LS, Kurtz J, Larison LM, Brewer WJ, Papoutsakis C. Nutrition Care Process Quality Evaluation and Standardization Tool: The Next Frontier in Quality Evaluation of Documentation. J Acad Nutr Diet. 2021;122(3):650-660.  

Colin C, Arikawa A, Lewis S, et al. Documentation of the Evidence-Diagnosis Link Predicts Nutrition Diagnosis Resolution in the Academy of Nutrition and Dietetics’ Diabetes Mellitus Registry Study: A Secondary Analysis of Nutrition Care Process Outcomes. Front Nutr. 2023;10:1011958. https://doi.org/10.3389/fnut.2023.1011958  

Composition of a Medical Record. NIH National Cancer Institute website. Accessed January 25, 2026.https://training.seer.cancer.gov/abstracting/record.  

Shults A. ADIME Charting Format. Dietitian Direction website. Published September 18, 2024. Accessed January 25, 2026. https://dietitiandirection.com/adime/.  

Malnutrition Diagnosis and Documentation: Strategies for Success. American Society for Parenteral and Enteral Nutrition website. Accessed January 25, 2026. https://nutritioncare.org/wp-content/uploads/2024/12/Malnutrition-Diagnosis-Documentation-Strategies-for-Success.pdf.