Query Yes/No for Malnutrition
The information in this query is fictitious. I need your thoughts on if this type of query would be seen as non-compliant. I have been informed by one of coders that this is non-compliant because we are asking a provider to agree or disagree with a Nutritional Diagnosis. I disagree. Your thoughts please??
Please review the following and provide your response in the progress notes.
85-year-old female admitted for frequent falls, AKI, and cystitis
ED note indicates patient has been “eating less than 300 calories a day due to decreased appetite”
4/2 Nutritional consult note indicates, "25% weight loss in the last 6 months...has been eating 1 meal per day...15% weight loss in the past 3 months...has not ate in more than 2 days prior to arrival...edema noted"
Nutrition dx: “Severe Protein Calorie Malnutrition r/t achalasia, failure to thrive in adult AEB 15% wt loss in 3 months and less than 50% of estimated energy requirements for more than 5 days."
Treated with ensure with all meals, snacks between meals, and calorie count.
Do you agree with the dietician's nutritional diagnosis of Severe Protein Calorie Malnutrition?
- Other (please specify):___________________
- Unable to determine