Monitoring, Evaluation, and Documentation
Core concepts
Monitoring and evaluation determine whether the intervention is working. Know which indicators to track (weight, intake, labs, symptoms, goal progress), how often to reassess, and how to document using standardized language. Documentation should follow a consistent format (e.g., ADIME: Assessment, Diagnosis, Intervention, Monitoring/Evaluation) and be accurate, timely, and objective. Understand the difference between monitoring (ongoing data collection) and evaluation (judging progress against goals).
Traps
Questions often test whether the chosen indicator actually measures the goal-weight for a weight-gain goal, intake records for an adequacy goal. Watch for documentation that includes subjective opinion without objective data, or that omits the monitoring plan. Distinguish a reassessment interval that is too frequent or too infrequent for the setting.
Rule of thumb
Every intervention should have a paired indicator and timeframe. Worked example: goal-increase protein intake to 1.2 g/kg/day within two weeks; indicator-3-day food record at week two; evaluation-compare calculated intake to target and adjust.
Study anchor
Use ADIME to structure documentation and confirm each intervention has a measurable indicator and a reassessment date.