Case Study
Your facility has recently adopted a new method of documenting in the medical record consistent with the American Dietetic Association's nutrition care process.You were trained using the SOAP method.You need to answer the following questions so that your transition to the new documentation method is smooth.
-When developing your PES statement, the signs and symptoms will likely come from which part of your ADIME note?

Question

Quizplus · Accepted Answer

The signs and symptoms will likely come from the Assessment (A) part of the ADIME note. The signs and symptoms for developing the PES statement come from the "A" (Assessment) section of the ADIME note, which includes information about the patient's medical history, physical assessment, laboratory values, and other pertinent data. The PES statement includes a description of the Problem (P), related to the patient's signs and symptoms identified in the Assessment. The E (Etiology) component of the PES statement describes the underlying cause or contributing factors, based on the analysis of the patient data. Finally, the S (Symptoms) section of the PES statement describes the patient's current symptoms, which may continue to be monitored and measured to evaluate the effectiveness of the nutrition intervention.

Case Study Your Facility Has Recently Adopted a New Method of Documenting