severe protein calorie malnutrition

Can I please ask what guidelines everyone uses to query for severe malnutrition or severe protein calorie malnutrition?

Comments

  • edited May 2016
    We do don’t use guidelines, we query based on dietary's assessment and ask if physician agrees with assessment
  • We really depend on our dietitians for this as do our MD's. They prefer to have the dietitians consult and then generally concur with their findings. Therefore, we rarely query without a dietitians consult.
    It works like this:
    If we identify a patient that we are concerned about that does not have a nutrition consult, we generally contact the dietitian directly, describe our concerns and see if they agree that a consult is needed. Then they will contact the MD and have a consult written. Then, any time our dietitians make a dx of malnutrition, they email one of the CDS. The CDS then does a quick review of the record to see if malnutrition is included in the documentation. If it is not, or we do not have the required severity, we query. This has been a collaborative process that has developed over time. We LOVE it, as it gets what we need. But our nutritionists love it too. They even calculated impact and used the results as a way to defend their need for additional FTE's last year!

    I have attached their reference sheet for you as well.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • edited May 2016
    Thank you so much. We are getting hit with RAC audits for this. I am looking to improve our process in this area to try and help prevent further audits. I like the tool. It is similar to what our dietician assessment is in meditech but I think we might be able to add a few things.

    Thanks again.

    Tracy M Peyton RN, CCDS
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406
  • edited May 2016
    The attached form is what our Dieticians use to communicate with our physicians. The dietician completes the form, places it in the progress notes for the physician to prompt for malnutrition. This is not a part of the permanent medical record. We have had great, great success.
    Our process is extremely similar to Katy's process. Our physicians are very dependent on our dietician documentation for malnutrition.

    Dorie Douthit, RHIT,CCS
    ddouthit@stmarysathens.org
    CDI Program/HIM
    706-389-3364
    St. Mary's Health Care System
    1230 Baxter Street
    Athens, Georgia 30606
  • edited May 2016
    Thanks to everyone for your assistance.

    Tracy M Peyton RN, CCDS
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406
  • edited May 2016
    We monitor the BMI, albumin, total protein and pre-albumin if available.
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