Query for Nutritional Status

byrd06byrd06
in CDI Talk Archive
At my hospital, the dietary team makes nutritional assessments of patients. While not a provider, the dietitian is the first person to introduce the term malnutrition in the patient on their assessment notes. How do we in CDI and coding use this information to get the doctor to document malnutrition without introducing the diagnosis and without sending over multiple queries? Thanks in advance.

Corrine Byrd, RHIT
Clinical Documentation Improvement Manager
Health Information Management
ccbyrd@mdanderson.org
T 713-792-2262

Comments

  • martin.conroymartin.conroy
    edited April 2016
    The diagnosis is already in the patient's record. You need the doctor to document in their progress notes if they agree with the assessment & plan.
    You are not introducing just asking for confirmation.

    Marty Conroy
    Temple Health
  • ggoodman@virginiahospitalcenter.comggoodman@virginiahospitalcenter.com
    edited April 2016
    Agree-you would not be introducing a new diagnosis :)

    Greta Goodman, CCDS
    Clinical Documentation Improvement Specialist
    Health Information Management
    Virginia Hospital Center
    1701 North George Mason Drive
    Arlington, VA 22205
    703-558-5336
    ggoodman@virginiahospitalcenter.com






  • annnd2009@gmail.comannnd2009@gmail.com
    edited April 2016
    Hi,

    I’d include the dietician’s clinical indicators as well to help provider not NEED to verify in their note if the information is already present. I’d also proved the actual types of malnutrition as choices as opposed to seeking a yes/no answer. Even if it might be acceptable, it makes it clearer and stronger I think.


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    We include the dieticians clinical indicators and assessment and ask for the physicians assessment providing the types of malnutrition, other, unable to determine as responses. We have a system where we are notified by dietary everytime they make a nutrition-related dx so that we don’t miss this low-hanging fruit.

    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


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