How do you write a SOAP or ADIME note for a nutrition client?
In short: A SOAP note organises clinical documentation into four sections: Subjective (what the client reports), Objective (measurable or observable information), Assessment (professional interpretation) and Plan (agreed actions and follow-up). ADIME is a nutrition-specific documentation format aligned with the Nutrition Care Process: Assessment, Diagnosis, Intervention, and Monitoring and Evaluation. Nutrition diagnoses are commonly documented using a PES statement (Problem, Etiology, Signs and Symptoms). Both formats support clear, structured records that distinguish client-reported information from professional interpretation and document measurable follow-up actions.
1 min 6 s videoCaptions onUpdated 9 October 2026
What goes in a SOAP note
SOAP is the format most health professions share, so it's the one a GP, physio or psychologist will read without effort. The discipline is keeping each piece of information in the right box.
| Section | What goes in | Example line (fictional client) |
|---|---|---|
| Subjective | What the client reports: symptoms, diet recall, appetite, how the plan went, their own words | "I skip breakfast most days and I'm starving by 3pm." |
| Objective | Measured or independently verified information, such as anthropometric measurements, laboratory results and clinical observations. Quantified self-reported data may also be recorded here if clearly identified as self-reported. | Weight 88.4 kg (down 1.2 kg in 4 weeks). Self-reported food diary: 5 of 7 days logged. |
| Assessment | Your professional reading of the above: progress, adequacy, barriers | Client reports increased afternoon hunger, potentially associated with prolonged periods without eating earlier in the day. |
| Plan | What you agreed, education given, referrals, when you follow up | Add a protein breakfast on workdays. Review diary in 2 weeks. |
The most common mistake is putting interpretation in Subjective or Objective. "Client eats poorly" is an assessment, and a vague one. "Client reports takeaway 4 nights a week" is a fact.
ADIME and the PES statement
The Nutrition Care Process (NCP) is a structured clinical care framework with four steps. ADIME is a documentation format aligned with those steps. SOAP is not a formal step or component of the NCP, but it can document care delivered through the NCP, provided the relevant assessment, nutrition diagnosis, intervention and monitoring information is captured. In ADIME, Assessment gathers food and nutrition history, anthropometrics, biochemical data, clinical findings and client history. Diagnosis names the nutrition problem you can treat. Intervention is what you'll do about it. Monitoring and Evaluation says which indicators you'll track and what counts as progress.
The diagnosis is written as a PES statement: the Problem, its Etiology (the cause), and the Signs and Symptoms that show it.
[Problem] related to [etiology] as evidenced by [signs and symptoms] Inadequate fibre intake related to limited consumption of fibre-rich foods as evidenced by a seven-day dietary assessment estimating an average fibre intake of 12 g/day, below the UK adult recommendation of 30 g/day
A well-constructed PES statement identifies a nutrition problem supported by assessment findings, describes its likely contributing factors and includes measurable signs or symptoms. The underlying cause should be addressed through nutrition intervention where possible. Our PES statement generator helps you phrase one.
A short worked ADIME note
Here is an initial consult for a fictional client, a 52-year-old office worker referred for raised blood glucose. Notice how short each section can be.
- Assessment. Weight 94 kg, height 176 cm, BMI 30.3 kg/m². HbA1c 50 mmol/mol documented in GP referral, with diabetes status and follow-up to be confirmed with the referring clinician. Dietary recall indicates approximately three 330 ml cans of regular cola daily, alongside a sandwich lunch and large pasta dinner. Using an illustrative label value of about 35 g of sugar per can (this varies between products), that is approximately 105 g of free sugars a day, above the UK adult recommendation of no more than 30 g. Client reports being unaware of how much sugar regular cola contains. Client reports a sedentary job and walking the dog at weekends.
- Diagnosis. Inappropriate intake of types of carbohydrate (free sugars from drinks) related to limited awareness of the sugar content of regular cola, as evidenced by reported consumption of three 330 ml cans daily, providing approximately 105 g of free sugars (illustrative estimate).
- Intervention. Explained how much sugar a can of regular cola contains and showed the client how to read drink labels. Discussed replacing regular cola with water or sugar-free alternatives. Agreed an initial, achievable behaviour-change goal of reducing regular cola from three cans to no more than one can daily for the next two weeks. One can still provides approximately 35 g of free sugars, which exceeds the UK adult recommendation of no more than 30 g per day even before other dietary sources, so this is a realistic first step. Review progress after two weeks and work towards further reducing free-sugar intake over time. Provided practical education on balanced meals and carbohydrate quality.
- Monitoring and Evaluation. Monitor cans of cola per day and estimated free sugars from drinks (g/day) from a food diary, days of the diary completed, and weight at each visit. Review in two weeks against the goal of no more than one can daily, and coordinate with the GP regarding HbA1c follow-up.
SOAP or ADIME: which should you use?
Choosing between SOAP and ADIME depends on your professional role, workplace requirements and documentation needs.
ADIME is particularly useful for dietitians and other appropriately trained professionals using the Nutrition Care Process, as it links nutrition assessment to a defined nutrition diagnosis, intervention and measurable outcomes.
SOAP is widely used across healthcare disciplines and may be appropriate when documenting consultations for multidisciplinary teams or when a general clinical format is preferred. You can follow the NCP and still document your work in SOAP format.
Whichever format you use, documentation should remain within your professional scope of practice, follow relevant organisational requirements and clearly distinguish nutrition-related assessments from medical diagnoses.
A client file where every note has the same shape is far quicker to review before a session. For more on the process behind ADIME, see the nutrition care process.
Habits that make notes hold up
- Complete notes as soon as practicable after the consultation, ideally on the same day, following any relevant professional or organisational documentation requirements.
- Quote the client when their words matter, and label it as their report.
- Use neutral language. "Didn't follow the plan this week" beats "non-compliant".
- Make every goal checkable: a number, a frequency or a date.
- Maintain an accurate audit trail. Corrections to finalised records should follow the record-keeping system's procedures, preserving the original entry and clearly recording who made the correction and when. Use a dated addendum where appropriate.
How to do it in Foodzilla
Foodzilla has SOAP and ADIME built in as note types, with a prompt in each section, and lets you sign and lock a note once it is final. Client notes are included on the Professional plan and above.
- 1Go to Clients, open the client's menu and choose Notes & Files, then press New Note. You can also press Add Note on the client's dashboard.
- 2Under Note type, pick SOAP or ADIME. Both carry a Built-in badge, next to Initial Consultation, Follow-up Session and Blank note.
- 3Give the note a title and fill in each section. Every section shows a prompt of what belongs there, and the Diagnosis section in ADIME asks for a PES statement.
- 4Set the Note date, and add an attachment if you need one, such as lab results (PDF, DOC, DOCX, TXT, JPEG or PNG, up to 10 MB).
- 5Choose Private to keep the note to you and your team, or Shared so the client can read it in their portal. Then press Save note.
- 6When the note is final, open it again and press Sign & Lock. A signed note can no longer be edited, and anything you add later goes in as an addendum.
Good to know
- One nutrition problem per PES statementEach PES statement should focus on a single nutrition diagnosis. If the assessment identifies multiple distinct nutrition problems, document them separately and prioritise them according to clinical significance and the client's needs.
- Quantify dietary informationWhere appropriate, summarise measurable information from food diaries, such as the number of days recorded, average reported intake or frequency of specific foods. Clearly identify these figures as self-reported and interpret them alongside other assessment findings.
- Provide a clear client-facing planClinical notes should accurately document assessment findings, professional reasoning and agreed interventions. A separate, accessible summary of the client's goals and next steps can help support adherence. Remember that clients may have the right to access their clinical records under applicable data protection laws.