RE: [EXTERNAL] RE: Is anyone out there using Dietary Consults to get Severe PCM documentation?
I’m with Don. I also use multiple choice and include the clinical guidelines for adult malnutrition. Normally the question asked is the clinical significance if any of the dieticians findings. Sometimes I get no significance, sometimes I’ll get malnutrition. But since our RD’s are the experts here the clinical significance of their findings is what I query on, not a diagnosis which doesn’t exist yet in the health record.
Robert
Robert S. Hodges MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
Secretary, Nursing Professional Standards Board
Aleda E. Lutz VA Medical Center
1500 Weiss Street, ATTN PAS-136
Saginaw MI 48602
989-497-2500 x13101
Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
Robert
Robert S. Hodges MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
Secretary, Nursing Professional Standards Board
Aleda E. Lutz VA Medical Center
1500 Weiss Street, ATTN PAS-136
Saginaw MI 48602
989-497-2500 x13101
Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens