If you prior role as a registered nurse you called the dietician to assess patients which exhibited signs and/or symptoms of malnutrition. I'm currently a CDIS can I still call the dietician to assess the patient?
Our CDI department has established a close relationship with our Clinical Dieticians. We have collaborated on development of our hospital guidelines for malnutrition and I provide some education to all the new interns on the importance of their documentation with the potential impact and ramifications. In addition, when we are reviewing a record where we feel it would be important for the dietician to weigh in (ie: a physician may document severe PCM but there is no nutrition consult or the patient appears to be malnourished but the dietician has not assessed), we contact the dietician to see if the patient is on their radar. They will assess the patient regardless of whether an official nursing consult has been ordered based on what we share for documentation in the record. With severe PCM being such an audit risk, we also share denial information so they may further understand the importance of their assessments and documentation. This has proven to be very positive.
Going along with this, as RN's we once were able to enter height and weight information which would calculate a BMI. In our facility, we often find the height and weight values, but the BMI has not been entered/calculated. Are there any opinions around allowing the CDIS' to enter the BMI when the current height and weight are documented as it is only a calculated value? Do any facilities do this? Currently we call the bedside nursing staff to complete this documentation in the record.
We do not formally consult dieticians in the medical record with an order. However, we have a close collaborative relationship and worked to incorporate ASPEN criteria into their assessments. We just send them an email with the patient information and ask them to evaluate.
We do not enter anything into the medical record except queries.