Malnutrition documentation

dschrader71

The dieticians within our organization are trying to find ways to capture better physician documentation for malnutrition.  They are currently working with the IT department to create a dieticians note in the EHR that will require a physician co-sign.   I am inquiring to see if other organizations are utilizing any or other opportunities to capture malnutrition.

Any and all input is greatly appreciated

cynthia.mead@nahealth.com

Our dieticians have created a beautiful assessment and plan in our EHR. I can't download a copy but if you send me your email I can send you pictures of it.

I would be interested in hearing what everyone thinks about sending a full RD assessment and plan to the MD to co sign to get the malnutrition diagnosis included in the record.

Currently we query using the information provided by the RD. I think having the MD cosign makes more sense, but I lost that argument. Same with the comprehensive WOCN assessments and plans.

Cynthia

Cynthia.mead@nahealth.com

dschrader71

cynthia.mead@nahealth.com said:

Our dieticians have created a beautiful assessment and plan in our EHR. I can't download a copy but if you send me your email I can send you pictures of it.

I would be interested in hearing what everyone thinks about sending a full RD assessment and plan to the MD to co sign to get the malnutrition diagnosis included in the record.

Currently we query using the information provided by the RD. I think having the MD cosign makes more sense, but I lost that argument. Same with the comprehensive WOCN assessments and plans.

Cynthia

Cynthia.mead@nahealth.com

That would be greatly appreciated!!!  My email is diane.schrader@hrhonline.org

jackietouch@aol.com

cynthia.mead@nahealth.com said:

Our dieticians have created a beautiful assessment and plan in our EHR. I can't download a copy but if you send me your email I can send you pictures of it.

Currently we query using the information provided by the RD. I think having the MD cosign makes more sense, but I lost that argument. Same with the comprehensive WOCN assessments and plans.

Cynthia

Cynthia.mead@nahealth.com

We follow a similar process. Our RDs complete their assessment and assign a malnutrition diagnosis (when appropriate) with the degree, indicators, risk factors and plan. They then send a document to the attending MD that specifies the malnutrition diagnosis and degree with a place for signature or an option to specify alternate diagnosis. A portion of their assessment populates the form, not the full assessment.

The process sometimes breaks down when the RD does not send the electronic form to the MD for signature. When this occurs, CDI contacts the RD to send the form so that the diagnosis can be captured.

Jackie Touch, RN, MSN, CCDS, CCM
CHOC Children's Hospital
Orange, CA

lprescott1

Many organizations do use this process and I think it does assist with communication between the disciplines. I would caution that a cosign of note by a provider does not necessarily indicate a diagnosis. the provider is the only one who can make a medical diagnosis. The provider must indicate they have assessed the patient and agree with and apply their own diagnosis or you may be at risk for a denial. A cosignature can be interpreted as simply meaning the provider read the note. 

vparent@emhs.org

Our dieticians are going to be participating in new education for themselves called "Nutrition Focused Physical Assessment". Once completed they will be meeting with physicians to preview their new additional documentation and where they can find it in the EMR. Thereby encouraging them to preview it to avoid being asked a query.