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
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.