CLINICAL DOCUMENTATION PEARLS

DECEMBER 2012

Malnutrition

Although we’ve recently discussed malnutrition, it is worth mentioning again because we often query for malnutrition and its severity and receive only a response that the patient has malnutrition, with no further detail. When the dietician identifies a patient with some degree of malnutrition, she alerts both the physician, for an appropriate plan to treat the condition, and the Clinical Documentation Specialist (CDS) team. A CDS reviews the chart and queries the physician if malnutrition has not yet been documented in a clinical note. The query always mentions the dietician-determined degree of malnutrition. Please review and consider both the dietician’s nutrition supplementation suggestions and her assessment of the severity of the condition and order and document accordingly. While a diagnosis of malnutrition will have an impact on the severity of illness of a case, a more specific nutritional diagnosis (i.e. one that indicates the degree of the malnutrition) better characterizes the patient’s nutritional status.

Documentation Tip—History Of

Be mindful of using the phrase “history of” when documenting a currently active problem, as a coder will be unable to capture that diagnosis as a current problem. For instance, a physician might describe a “diabetic patient with nausea and vomiting and a history of diabetic gastroparesis.” While the physician may have intended to indicate that the nausea and vomiting were caused by the gastroparesis, coding rules enable only the symptoms nausea and vomiting to be coded, and the gastroparesis would not be listed as a current diagnosis unless further clarified with a query.

Some other commonly seen active conditions that are often documented only as “history of”, thereby failing to accurately portray the patient’s current condition or enable complete coding of his chart, include:

abdominal aortic aneurysm

breast cancer

CHF

chronic respiratory failure

pancreatitis

peripheral neuropathy

recurrent UTIs

sleep apnea being treated with C-PAP

seizure disorders

wounds

If you are evaluating and/or treating these and other chronic conditions during a patient’s hospitalization, even if they are not the primary reason for the patient’s admission, please make it clear to anyone reading the chart that you are doing so. Tell the patient’s whole story and get credit for the care you’re providing.

Please don’t hesitate to call your helpful and friendly CDS’s at ext. 8641. We are

always happy to discuss your documentation questions and concerns.