Q&A: Partnering with dietitians to obtain malnutrition documentation

CDI Strategies - Volume 16, Issue 9

Q: We do many queries for malnutrition and are looking for a better way to get this essential diagnosis into the medical record without a query. I understand that some organizations have the dietitian document it and the provider attest to the diagnosis. Is that acceptable practice? Our thought is that if the notes were cosigned, malnutrition would be charted more through the record than what happens when we get it on a query once.

A: Malnutrition among hospitalized patients remains a serious issue, affecting more than 30% of hospitalized patients in the United States, per studies cited by the Agency for Healthcare Research and Quality, ACDIS Director Brian Murphy wrote in a 2021 CDI Strategies note. Per the same study malnutrition is associated with high mortality and morbidity, functional decline, prolonged hospital stays, and increased healthcare costs. Patients with this diagnosis get readmitted at a rate some 50% higher compared to patients with no associated malnutrition.

Sarasota (Florida) Memorial Hospital developed a structured note directed to the provider which is automatically generated when registered dietitian (RD) evaluates the patient and identifies a form of possible malnutrition, explains Deb Dallos, RN, CDIP, revenue integrity analyst there. This, in turn, requires the provider to sign the structured note addressing the type and severity of malnutrition. The provider is alerted to the incomplete documentation via the organization’s EMR which notates the document as incomplete until the provider addresses the concern. “We also had a hard stop built into the EMR where the provider cannot enter orders until he addressed the malnutrition,” with the option of agreeing or disagreeing with the findings of the RD, Dallos says.

At WVU Medicine, in Morgantown, West Virginia, the CDI team teaches providers to bring forward the dietitian’s diagnosis forward into their progress note and plan-of-care as warranted in order to reduce the potential for claims denials, says C. Dawn Diven, RN, CCDS, CDIP, CCDS-O, enterprise system CDI director there.

The physician needs to add the documentation to notes and discharge summary, agrees Nancy Franciotti, RN, CCDS, CDI manager at Inspira Health in New Jersey. “The diagnosis of malnutrition is such a focus of the OIG, the advice has always been to over document it. Teaching physicians to answer questions such as: ‘How does it affect the disease process patient was admitted with? How are you treating it? How is it being conveyed to discharge site?’ within the medical record documentation can really help.”

Editor’s Note: This question was posed and responded to as part of the ACDIS Leadership Council and Exchange networks.