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Energy and protein intake of most hospitalized patients are often reported to be less than 80% of the requirement. While continuous effort has been made to identify patients at high risk of malnutrition, relatively lesser emphasis has been made in monitoring and documentation of nutritional intake. OBJECTIVES: To validate and evaluate the Pictorial Dietary Assessment Tool (PDAT). METHODS: A validation study involved healthcare professionals who estimate 130 meals consumed by 67 patients using PDAT. Agreement between methods and different staffs was analysed using Bland-Altman plots, Kappa Statistics, and Intra-class Correlation Coefficient. A cross-over intervention study was conducted among 132 hospitalized patients with diabetes to evaluate the implementation of PDAT. Cost and time of PDAT in comparison to Comstock was estimated using the activity-based costing approach. Accuracy was expressed as the percentages of energy and protein obtained by both methods, of those obtained by the food weighing. RESULTS: The 95% limits of agreement between the two methods ranged from -108 to 115 (energy), -7.2 to 6.8 (protein). PDAT and food weighing showed a satisfactory agreement beyond chance (k) (0.81 for staple food and animal-source protein; 0.735 for non-animal-source protein). Intra-class correlation coefficient ranged between 0.91-0.96 among healthcare staffs. Time to complete the food intake recording of patients using PDAT (2.31 ± 0.70 minutes) was shorter than Comstock (3.53 ± 1.27 minutes), (P<0.001). Overall cost per patient was slightly higher for PDAT (USD 0.27 ± 0.02) than for Comstock (USD 0.26 ± 0.04),(P<0.05). The accuracy of energy and protein intake estimated by Comstock was 10% and 30% lower than that of PDAT, respectively. CONCLUSIONS: PDAT provides a valid estimation and required a shorter time to be completed than Comstock, but more costly. However, only USD 0.01 is needed to increase the accuracy of the estimation of energy intake by 10% and protein intake by 30% when using PDAT.