Documentation of Malnutrition- Leading: Yes or No??

My organization, like many others has been trying to come up with a process for documentation to assist with the identification and diagnosis of malnutrition.  My question is in regards to the wording that the dietitians are using in their documentation and is it considered leading?  Are they held to the AHIMA practice brief standard for compliant query practice since it is not a query, but they are making a recommendation for a diagnosis to a physician?  Some of the wording that is being used in their nutrition notes is 

Assessment of Malnutrition:  Malnutrition present upon admission.

 Recommend diagnosis of severe protein-calorie malnutrition in the context of chronic illness based on weight loss and energy intake.


When MDs do not add malnutrition to their progress notes, they are also putting in progress notes; “MDs please add moderate protein calorie malnutrition to progress notes for coding and reimbursement. See RD note for details”   

I have made a suggestion to them to document "meets criteria for per ASPEN guidelines_______".  But I am curious to know your thoughts and opinions on this matter. I know this is a highly targeted and scrutinized diagnosis, so want to be sure.


  • The nutrition notes state, "The patient meets criteria for malnutrition." In the progress notes, please confirm your agreement or disagreement with the nutrition consultants assessment.  

    How's that work.
  • Leading in my opinion

    The RD assessment should state the nutritional dx and then it's up to the Provider to bring into their notes to show the clinical relevance. This can also be achieved via a query from CDI or Coding. The RD should not be documenting anything related to reimbursement in their notes (my opinion)


  • Agree with Jeff that the RD should not be including the language referencing reimbursement.

    I do believe it appropriate for the RD to document their findings of malnutrition and of degree based on their assessment with the ASPEN criteria.

    I believe it is appropriate to query the physician quoting the RD assessment findings, asking the physician to present their assessment of the pt's nutritional status, and offering a compliant MULTIPLE choice menu of options.

    In my opinion, it is NOT COMPLIANT to use a yes/no (or similar to, as quoted above) query format IF the physician has not documented malnutrition (of any degree).

  • I agree with jeff above. We are presently working on an update to the AHIMA/ACDIS Query practice brief and are now discussing that fact that documentation clarifications such as this should be considered as a query and follow the same guidance. The compliance considerations do not apply only to CDIs and coders- they should apply to anyone seeking clarification in the documented record.
  • I  feel like our chuckherbt query is leading. ( no offence please) 

     I understand that malnutrition is a subject that is subject to controversy as well as for denials. I am a rookie in a facility without a make suggestions; Still, I am practicing my querying skills here expecting an expert to correct me. Further, patient info is unknown. I prefer to write Multiple choice queries. 
    I would Tailor and target to patient but around criteria below.

     Per Nutritional assessment/Dietitian  - Nutritional findings.........
     Patient is on NG feeds/PEG or.... 
     patient had been suffering with chronic illness( condition)/living alone,or has an acute illness  (condition)....
    Past medical history indicate an unintentional  weight loss ,

    Physical exam. Loss of muscle  mass, 
                             Loss subcutaneous fat 
          and/ or,      diminished/reduced hand grip strength,BMI

    For clinical significance, please specify,
    The patient has,
    1. mild malnutrition,
    2. moderate malnutrition, 
    3. Severe malnutrition
    4. Protein calorie malnutrition, 
    5. No malnutrition
    6. Other Please specify...........
    7. clinically unable to determine----------
  • Morning, I'm inquiring if there are facilities out there that when it comes to querying for the degree of malnutrition, does one only query if it's Non-severe (E46) vs. Severe (E43). I am being told that based on ASPEN criteria, the facility will only be querying to clarify those and not inclusive of Mild or Moderate.

    By the way, the facility specifically will go by ASPEN standards for now, they don't look into GLIM, which would have at least provided me a good resource to provide to them. The response is: RD uses the ASPEN guidelines to diagnosis but the ASPEN guideline doesn’t dx for mild."

    I had thought Aspen does provide a guideline for mild stating (

    "Chronic disease-related malnutrition": inflammation is chronic and of mild to moderate degree (e.g., organ failure, pancreatic cancer, rheumatoid arthritis or sarcopenic obesity)"Am I wrong in this? Based on ICD-10 codes, it's "blasted out" the difference in mild, moderate, and severe. Any resources to vet out why it's important to query for also mild, moderate and severe vs. just the two would be welcomed

    Thank you!

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