severe malnutrition based on BMI only

angelamckee@uh.organgelamckee@uh.org
in CDI Talk Archive
We are having a problem with RD's placing a "Nutrition Services Communication Label" on physician progress notes asking for severe
protein calorie malnutrition based on BMI

Comments

  • lrubinlrubin
    I would ask to review their guidelines because you can have a BMI
  • catladyrncatladyrn
    I agree that you should ask to review their alleged guidelines, and then you might want to educate them on documentation standards and why their requests could cause big problems for the hospital. I've also never heard of queries generated by dietitians. If we as CDS nurses are being held to AHIMA standards despite not being coders, then the dietitians need to follow them as well. Might want to suggest they run the queries through you.

    Renee


    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
  • dong.lidong.li
    edited May 2016
    I don't think it is appropriated for them to asking this question only regarding BMI, I talked with our RD and she said she cannot tell doctor what to document in progress notes, what she can do just a suggestion on her assessment notes, and she said there is no guide line here to support this action.

    Thanks


    Mei Li, RN, MHA, CDIS
    Clinical Documentation Specialist
    West Houston Medical Center
    12141 Richmond Ave
    Houston, Tx 77082
    Tel: 281 588 8560
    Cel: 832 878 2518
    Email: Dong.Li@hcahealthcare.com
  • angelamckee@uh.organgelamckee@uh.org
    The nutrition services communication label went through the HIS department and forms committee for approval. We belong to the Performance Improvement department and had no input prior to seeing the form on the charts.
    Their guidelines are ambiguous at best, and as with Coding Clinic, can be interrupted in several different ways.
    I have made copies of several of these labels in which there is no
    malnutrition clinically. I have a copy of one in which there were no lab results on the record, but they still asked for severe protein calorie malnutrition. I am gathering this information before addressing it with the nutrition department director.
    Any other advice?
  • catladyrncatladyrn
    I hope they realize that by adding a sticky to the progress notes, they basically have a query on the chart, which will automatically be included in the medical record and will be subject to audit. Perhaps they could be persuaded to modify their form so that the physician can review the data and be allowed to check off one of the malnutrition options (e.g., PCM, severe PCM, etc.), rather than being mandated for a particular choice.

    Are you a solo hospital or do you belong to a chain? Would be interested in knowing what the other hospitals in your group are doing.

    You are the expert on clinical documentation and they need to understand that and work with you.

    Renee


    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
  • kshumpertkshumpert
    edited May 2016
    Could you do some education with them regarding coding, reimbursement, RAC and other auditing agencies? I have found that when I educate others in the facility regarding their documentation and the impact to the organization, it improves things and I get the outcome I had hoped to achieve. Or, perhaps you could meet with the coders and HIM director and explain your concerns. If it is not referred to by the attending or addressed in the discharge summary perhaps you can discount it. We had an issue with staging decubitus ulcers. We had nurses staging all over the place. I met with nursing administration and we decided as a group that the beside nurses weren't going to stage and that it would be left to wound care to stage. We included in it our query policy as well to address those little nuances when we would get a rogue stage from a bedside nurse. Now, no more issues with our tissues:)


    Kathy
    Kathy Shumpert, RN, BSN

    Clinical Documentation Improvement Specialist
    Howard Regional Health System
    Office 765-864-8754
    Pager 765-604-0424
    Fax 765-453-8152

    There are thousands of thoughts lying within a man that he does not know till he takes up the pen and writes. ~William Makepeace Thackeray

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