CDI Ordering a Dietician Consult

aclay2@hfhs.org

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?

denise.worcester@mainegeneral.org

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.

Jane.Brown@ensemblehp.com

We do not enter nutrition consults and we do not enter BMIs.  In fact, I don't believe we even have the access to allow us to do this.  We have discussed both of these in the distant past and felt that it was a bit too close for comfort from a compliance standpoint.  I don't see anything specifically in the recent Practice Brief to address this though.  I would want to have an internal policy around it.  Interested to hear other's thoughts. 

ebraun

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.

evanspx@sutterhealth.org

My feelings are that CDS are not a part of the clinical team, as such, the CDI workflow should not be potentially be seen as causing any potential conflict of interest.   I agree a CDI Team would need to work in this issue very thoughtfully, consulting with Compliance and RD Leadership.  Having said that,   I do like the workflow offered above by Erica.  Our team does not enter anything in the record except a clarification.  We DO review the RD Assessments, asking the MD to review and comment when applicable.

Pe

denise.worcester@mainegeneral.org

We follow the same process as Erica. We do not order consults, but we do touch base with the dieticians depending on what we see in the documentation. We have a close collaboration but communication is either verbal or via email.

jackietouch@aol.com

We also follow the same process as Erica and Denise by emailing and asking if RD is aware of the patient. If we see that the MD has placed an order for RD consult, we review record daily for RD documentation and any query opportunities. We do not enter any heights/weights/BMIs into the record, but will discuss with the RD if values look suspect (pediatric patients, so sometimes lengths/heights are inaccurate).

ereshmak

My place, we were relying on the RD's notes that were built upon ASPEN criteria. If the MD did not document MN, we used to query for Mn and stage.  In the query we quoted RD's 
 "severe Protein Calorie Malnutrition " and sent a yes or No query. when the CDi lead said it looks leading we changed it in to a multiple choice query. Now he does not agree on it and he says we should  only include the signs of symptoms in the RD's note to query. Such as, muscle wasting and weight loss 3%in 2 weeks and suggestion for dietary modifications from the RD's note.   
Please guide me here, If I can include pressure  ulcer stages from nursing notes why is it wrong to use the quote "SPCM " from RD's  assessment? 

nameher

There is/are specific Coding Guidelines and Coding Clinic guidance regarding things that can and cannot be coded from nursing documentation.  Coding the stage of an already documented pressure ulcer (including anatomic site) from nursing documentation is appropriate.  

Clinical nutrition (RD) often have specific screening protocols leading to their evaluation.  Included are such things as NPO status and LOS.  Without 'consistent' physician documentation of the clinical indication/medical necessity for nutrition support, the fact that the RD made a nursing assessment does not equal a medical diagnosis.  When querying, it is not appropriate to introduce a diagnosis not already documented.  That is why we can offer the RD assessment based on clinical criteria i.e. muscle wasting, weight loss but the physician must make the diagnosis. 

Yes or No queries are rarely acceptable.  I would refer you to the AHIMA and ACDIS WhitePaper Guidelines for Achieving a Compliant Query Practice.  It is a very helpful document.

"Yes/No queries should only be employed to clarify documented diagnoses that need further specification."

When they say documented, they mean a physician diagnosis since only physicians can diagnosis.  So, if there is consistent, supporting documentation, a query would need to include multiple options as well as an unknown option.  A statement like, "the diagnosis represented by these clinical criteria" or "can this clinical scenario be best described as :" may help.