Malnutrition
I am not sure what to do on this patient or if I need to do anything. Any help I could get would be appreciated.
50 yr female was admitted for a intestinal perforation with abscess. She was admitted on 1/2/17 and was NPO until the morning of 1/5/17. She then started clear liquids. The dietician did see her. She was weighed the first 4 days and then not anymore. On admit, she weighed 145lbs. When weighed on the 3rd day, 173lbs was recorded without any mention of edema. I talked to the nurse who stated the patient wasn't edematous. We think the weights were wrong. On 1/6/17 the dietician did recommend TPN "in 2 days if diet not advanced". The doctor started the patient on TPN on 1/9/17 and documented malnutrition.
I'm using the CDI pocket guide, and she doesn't seem to meet the criteria for malnutrition. Any opinions? If she doesn't, should I query and how? Thanks
Comments
Since you have the risk factor of the GI disorder and the treatment of the dietary consult and TPN, you may need to query for your indicators.
What percentage of her diet is she consuming? Has the family had any observations that have been documented?
Our queries usually ask for additional clinical indicators that support the documented diagnosis.
Hope this helps a little!
Laura
ASPEN criteria with acute illness, we are struggling with capturing this diagnosis as the providers are not capturing this from the dietician assessment. Good luck!
Angie
Complicated issue...my personal preference is to cite in a query the relevant portions of the RD Assessment to the MD, asking them to comment on any clinical significance, and offering them context, clinical support, and compliant choices per the query. But, I do believe it is important to cite any RD Assessment given the complexities of this clinical issue.
Paul Evans, RHIA, CCDS