Dietician as "Consultant"
Recently our Dieticians have adopted a new set of guidelines for determining the degree of malnutrition. The new guidelines include things our Providers rarely document (like fat pad depletion and muscle wasting). The Dieticians are very good at documenting all of the necessary indicators in their notes. When querying the Provider to ask for degree of malnutrition would it be appropriate to ask if they 'agree with the Dietary consult"? Thanks, Rhonda
Comments
Our queries have the Dietary consult inserted and treatment and then a list of possible DX
A Registered Dietician/Hospitalist has documented the following clinical indicators:
Treatment:
Please clarify as:
Cachexia without malnutrition Nutritional risk without malnutrition Malnutrition, severity unknown Mild protein calorie malnutrition Moderate protein calorie malnutrition Severe protein calorie malnutrition Unspecified protein calorie malnutrition Marasmus Kwashiorkor-a specified severe Protein malnutrition Other (please specify) _________________Clinically unable to determinePer the Guidelines for Achieving a Compliant Query Practice it states "In addition to present on admission (POA) determinations, yes/no queries may be utilized under the following circumstances: Substantiating or further specifying a diagnosis that is already present in the health record (i.e., findings in pathology, radiology, and other diagnostic reports) with interpretation by a physician."
Interpretation by a physician is the key to this guidance. Since the dietary consult diagnosis does not include interpretation by a physician, it would not seem compliant to use a yes/no query format.
Happy Memorial Day weekend everyone!