Q&A: Malnutrition documentation processes

CDI Strategies - Volume 14, Issue 26

Q: Our dietitians send cases needing a query for malnutrition to our CDI staff. Previously, they were notifying providers of the need for the documentation of the diagnosis directly, but from a compliance perspective, they were more comfortable with us owning the formal query process.

Now, however, my hospitalists are wondering if there is a better way to leverage technology to feed (no pun intended) the dietitians’ assessment and diagnosis back to the providers to minimize the query burden. Do you have any recommendations for processes that work well to ensure the dietitians’ assessment is followed up with documentation by the provider? Can the provider cosign the dietitian’s note?

A: At my organization, when the dietician completes their American Society for Parenteral and Enteral Nutrition (ASPEN) assessment for malnutrition (which may be in a consult note or a progress note), they send that note to the provider for them to cosign. The note appears in our system as usual, but it will say “waiting for cosign” until it is attested.

The provider is expected to attest the dietician note within 24 hours and add a sentence stating they agree with the dietician assessment of malnutrition and the treatment plan. The providers will then add malnutrition to the problem list and continue to document malnutrition in progress notes and the discharge summary. 

I did a lot of research on this topic when I began my role. Cosigning the dietician’s note is not enough documentation to capture the significance of the malnutrition. I personally know an organization that was audited for this practice. Our dieticians continue to alert us and we pose a query.

We also began physician education on malnutrition documentation and encouraged physicians to comment on the malnutrition as it relates to the principal diagnosis. We also encouraged them to carry the documentation into the discharge summary in order to inform the discharge site of the condition and any treatment ordered.

Editor’s note: This question was answered by Nancy Franciotti, RN, BS, CCDS, CDI manager at Inspira Health in Woodbury, New Jersey. Franciotti is a member of the ACDIS CDI Leadership Council. To learn more about the Council, click here.

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