The Importance of Proper Malnutrition Documentation Documenting malnutrition is important to gain better healthcare outcomes. This article examines this and the key documentation elements.
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Malnutrition diagnoses and their accurate documentation is important for providing quality care. The nutritional status may be a sign of a more serious condition. Many serious conditions including pancreatic cancer, lung cancer, head and neck cancer, gastrointestinal cancer, stroke and chronic obstructive pulmonary disease (COPD) have a high prevalence of associated malnutrition. Evaluating nutritional status during hospitalization and up-to-date documentation is very important, especially when the patient is hospitalized after surgery. Patients can develop malnutrition as a result of anorexia, iatrogenic starvation (for tests, anesthesia), inadequate attempts during oral feeding and prolonged ventilator support. A recent review published in the Nutrition in Clinical Practice (NCP), a peer-reviewed, interdisciplinary Journal of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) reveals that proper documentation of malnutrition diagnoses in the hospital can maximize patient care and reimbursement. Accurate documentation helps the healthcare teams classify a patient’s degree of malnutrition and determine how frequently they should reassess that patient’s response to care to ensure the best possible care. The review states that the major funding source for most hospitals in the United States is Medicare and the hospitals receive the payments through the Acute Care Hospital Inpatient Prospective Payment System, which classifies patients into Medical Severity Diagnosis-Related Groups (MS-DRGs) to take decision regarding payment amounts. With the proper documentation of co-morbidities and complications, the payment received by hospitals can be increased to offset patient care costs. In short, lack of appropriate malnutrition documentation prevents patients from receiving the care that they need by allowing hospitals to overlook malnutrition and come up with inaccurate diagnoses. This will also cause hospitals to miss out on the insurance payment they require to support the care of the patient.
Crucial Elements in Malnutrition Documentation According to the American Society of Parenteral and Enteral Nutrition (ASPEAN), adult malnutrition is diagnosed based on the presence of two or more of the following characteristics such as:
Inadequate energy intake Loss of weight Loss of muscle mass Loss of subcutaneous fat
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Accumulation of localized or generalized fluid Weakened functional status as measured by the strength of hand grip
Physicians should mention those characteristics in their documentation to ensure quality care. The key elements to include in malnutrition documentation are as follows:
History and Clinical Diagnosis – The patient’s history and the diagnosis details should be mentioned in your documentation. This will be helpful to suspect conditions that may be associated with the inflammatory processes and nutritional imbalance.
Clinical Signs and Physical Examination – The clinical signs for inflammation include the indicators associated with systemic inflammatory response syndrome such as fever or hypothermia, tachycardia and tachyhypnea. Physical examination may help identify fluid accumulation and the signs of weight gain or loss.
Anthropometric Data – This information includes body composition metrics such as height, weight (particularly being underweight), history of weight loss, characteristics of skin folds and circumference.
Laboratory Indicators – Though laboratory indicators like variations in hepatic proteins (low albumin or prealbumin) may not accurately measure nutritional imbalance, they are helpful in indicating morbidity and mortality. Laboratory indicators also include inflammation markers such as elevated C-reactive protein, elevated or low white blood cell count, and elevated glucose. More complex markers such as negative nitrogen balance and elevated metabolic rates can be also mentioned under laboratory indicators.
Dietary Data – This includes a modified diet history or a 24-hour diet recall of the patients. Usually, patients are given a form to complete and it is analyzed by a computer-based nutritional assessment program. However, this single sample may not be the reflection of a patient’s typical intake. Therefore, it is not a good idea to use the data as the sole assessment.
Functional Outcomes – An assessment of strength and physical performance and other associated findings should be mentioned under this section.
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An electronic health record (EHR) system will help to expedite the documentation process as it allows you to copy and paste information and abbreviate (for example, SPCM for severe protein calorie malnutrition). However, there is a greater chance for users to enter wrong details inadvertently if they copy and paste information without checking the content. Moreover, the reader of the malnutrition documentation may not have access to the approved abbreviation list of the hospital or there may be no approved abbreviation list for the hospital. This may cause the reader to misinterpret the abbreviation and lead to poor outcomes. Effective communication among the interdisciplinary team is very important as it can help physicians and team members understand what the dietician has identified and the suggested care plan. A combined approach of EHR and transcription can give you complete and accurate malnutrition documentation. In this approach, skilled and experienced transcriptionists transcribe the physician recordings and the transcribed data is populated into corresponding fields within the electronic record system. Professional transcription companies employ a dedicated quality assurance team to check whether the transcribe data is accurate before sending it to the electronic record system. In this way, you can ensure all the data within your documents is accurate and reliable.
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