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
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
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
Comments
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
Thanks again.
Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406
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
Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406