BMI Documentation
Hi-I have a question about BMI documentation. Our EMR calculates a BMI
when a height and weight are entered. In my hospital, heights and
weights are frequently entered by nursing unit assistants. Our coders
believe that they cannot code the BMI from this documentation since the
data is not entered by a "licensed clinician". I interpret coding
clinics, etc., to say that BMI's can be coded as long as they are part
of "official nursing documentation". In fact, I wrote to AHA in February
2011 and received that answer. Since state nurse practice acts delegate
duties like entering height and weight to assistive personnel, I think
this is "official nursing documentation". The supervising RN is
responsible to verify the accuracy of date entered by assistive
personnel.
Does anyone else have a similar issue? If so, what have you done about
it?
Cathy Seluke, RN, BSN, ACM, CCDS
Supervisor Clinical Documentation Compliance
MaineGeneral Medical Center
Augusta and Waterville, Maine
(207) 872-1796
Cathy.Seluke@mainegeneral.org
when a height and weight are entered. In my hospital, heights and
weights are frequently entered by nursing unit assistants. Our coders
believe that they cannot code the BMI from this documentation since the
data is not entered by a "licensed clinician". I interpret coding
clinics, etc., to say that BMI's can be coded as long as they are part
of "official nursing documentation". In fact, I wrote to AHA in February
2011 and received that answer. Since state nurse practice acts delegate
duties like entering height and weight to assistive personnel, I think
this is "official nursing documentation". The supervising RN is
responsible to verify the accuracy of date entered by assistive
personnel.
Does anyone else have a similar issue? If so, what have you done about
it?
Cathy Seluke, RN, BSN, ACM, CCDS
Supervisor Clinical Documentation Compliance
MaineGeneral Medical Center
Augusta and Waterville, Maine
(207) 872-1796
Cathy.Seluke@mainegeneral.org