Is anyone out there using Dietary Consults to get Severe PCM documentation?

m.leblanc

I was wondering if anyone is using a template such as the one below to get providers to utilize the dietician's diagnosis from their assessments?

Dear Dr. ____________________

The Registered Dietician diagnosed your patient with severe protein calorie malnutrition in the context of acute and/or chronic illness based on the physical findings:

• insufficient energy intake; ________
• weight loss; ________
• loss of muscle mass; ________
• loss of subcutaneous fat; ________
• localized or generalized fluid accumulation; and _______
• diminished functional status as measured by hand grip strength ________

According to The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines recommend that the diagnosis of adult malnutrition be based on the presence of two or more of the characteristics listed above.

Please document if you agree with the assessment diagnosis of Severe Protein Calorie Malnutrition:

Yes __________
No __________
Other dx ________
Unable to determine _________


Physician signature: _____________________ Date:_____________

What do people think?

Mark

katysuegood@gmail.com

We considered modifying our existing template and it looked similar to that. Basically stating that the Dietician had made a dx, providing the basis of that dx and asking if they agree. However, our coders were uncomfortable with it. While we are allowed to ask (yes/no) whether a physician agrees with a dx that is made by another provider, I think it is a grey area whether you can do this with a dietician, as they are not a physician. We ended up modifying the body of the query but keeping the original question which is open ended. Something like 'can you clarify the condition that the patient is being treated for' with the appropriate malnutrition options, other, unable to determine, etc.

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

dvitalone1

Our template is very similar except the choices are
I concur with dietitian's assessment of______________
I do not concur with dietitian's assessment of________________
Patient does have malnutrition but other type_______________
Pt does not have malnutrition
Other unknown

lmcnamara@cortlandregional.org

This is the query we use. Make front/back.

My 2 cents....In our department, we do not ALWAYS rely on RD's to make the call of malnutrition. As a RN, I feel that clinically a nutritional query can be left on the chart. i.e. Demented pt. with need for assist with meals, altered consistency diet, including liquids, disease process, BMI and more. (although not looking solely for severe PCM)


Lona McNamara, RN, BSN, CCM
Clinical Documentation Integrity Specialist
Cortland Regional Medical Center
607-428-5129

don.cdi.rn@gmail.com

I'd caution using a yes / no format when the only existence of the diagnosis of malnutrition is in the RD documentation. My concern is that may be viewed as non-compliant (since the original diagnosis is not offered by a physician, NP or PA).

We certainly do use the dieticians assessment and findings which do follow the ASPEN criteria. Additionally, the dieticians have been extensively trained and validated on focused physician exam for nutritional status (such as fat loss and muscle wasting).

We will use a multiple choice option menu that includes items such as severe or non-severe malnutrition, etc.

This combination approach (increased expert dietician assessment with query follow up, medical staff education and engagement -- our physician advisor and dietician manager have presented to a number of medical staff settings) has been quite successful with appropriate capture of nutritional status (which is a significant risk profiling diagnosis).

Don