Nutrition consult findings
We have a question about nutrition consults. If we now can take the wound nurse consult's notes for staging of malnutrition. Is there a possibility that we can use the nutrition consults that document stage of malnutrition and obesity rather than having to have the doctor's state it? e.g. malnutrition 2nd degree.... md has not documented it at all.
Comments
At our hospital, we must query. Even if the MD has documented malnutrition, we must query for specificity. The dietary note makes a great supporting document, though!
Laura
Same process as Laura. We include the dietary note in the query with great response. Even if the provider has documented the malnutrition, we still wont take the staging form nutrition.
Katy
The coding guidelines state:
Documentation for BMI, depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale
For the Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages,
and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.
Jackie Touch
We do not have a form, just a dietician note which clearly states the nutrition diagnosis and the degree of malnutrition if present. They also include the clinical indicators that led them to the diagnosis of malnutrition along with the BMI. We include all that information in our query that is taken right from their notes. They are the 'experts' and their information is very helpful.