Nutrition consult findings

ikperr2

We have a question about nutrition consults. If we now can take the wound nurse consult's notes for staging of malnutrition. Is there a possibility that we can use the nutrition consults that document stage of malnutrition and obesity rather than having to have the doctor's state it?  e.g. malnutrition 2nd degree.... md has not documented it at all.

laura.rogers@franciscanalliance.org

At our hospital, we must query. Even if the MD has documented malnutrition, we must query for specificity.  The dietary note makes a great supporting document, though!

Laura

katysuegood@gmail.com

Same process as Laura. We include the dietary note in the query with great response. Even if the provider has documented the malnutrition, we still wont take the staging form nutrition.

Katy

Amy_Stremming_1992

We do the same. We use the nutrition notes/diagnoses in our queries.
The coding guidelines state:

Documentation for BMI, depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale
For the Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes,  code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages,

and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.

jackietouch@aol.com

We also query for degree. We code BMI from RD assessment, but always clarify for malnutrition degree. We have a process in which our dieticians send a form to the MD with the degree of malnutrition specified, MD signs the form and the diagnosis is placed on the current diagnosis list/ progress note. If the dietician does not send the form, the CDS will clarify.

Jackie Touch

Amy_Stremming_1992

Yes, we also ask for the degree of malnutrition when we query.
We do not have a form, just a dietician note which clearly states the nutrition diagnosis and the degree of malnutrition if present. They also include the clinical indicators that led them to the diagnosis of malnutrition along with the BMI. We include all that information in our query that is taken right from their notes. They are the 'experts' and their information is very helpful.