Careteam and attending provider

Hi All,

All of the sudden we have experienced some push back on queries sent on certain dx. For ex, providers are responding with 'I did not treat the patient for malnutrition' in response to malnutrition query.

This seems to be an issue with providers being asked queried for dx that are primarily assessed/treated by other member of the care team (malnutrition, wounds, etc). for example, our nutritionists tend to identify and treat malnutrition, WCON's and nursing identify/treat pressure ulcers. There are some automated consults related to braden scores, BMI's, LOS, etc too so the provider is not always ordering the consult.

If you have provided education to your providers that you could share, that would be great. I am trying to figure out how to say what I want to say without sounds harsh ;-). If you have any sources that would support that providers should document these dx even if they themselves aren't primarily responsible for the treatment, that would be great.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • We just recently had our dietician's attend our Provider Education session with the Hospitalists, Residents, and Trauma to support our education on Malnutrition.
    This is our query:

    Dear Dr. and/or Current Provider,

    To best reflect care provided for this patient, please render your opinion as to whether or not the patient has SEVERE, MODERATE, MILD or UNSPECIFIED MALNUTRITION based upon Dietitian's assessment of and treatment with . Please document/discuss your opinion in the progress notes and discharge summary. Thank you.


    Rosie McKellips, RN, RHIT, CCDS, CCS-P
    Supervisor, Clinical Documentation Improvement
    North Memorial Health Care and Maple Grove Hospital
    763-581-4531






Sign In or Register to comment.