Documentation Tip of the Week: Malnutrition- Preventing Readmissions

Posted on Wed, Jul 08, 2015
Documentation Tip of the Week: Malnutrition- Preventing Readmissions

Our weekly feature of clinical documentation tips


  • Malnourished patients are more likely to develop a pressure ulcer in the hospital 
  • Malnourished patients are hospitalized longer than those screened and treated early 
  • Almost HALF of the patients who fall in the hospital are malnourished 
  • Patients with malnutrition have greater risk of surgical site infection

Malnutrition should be diagnosed when 2 or more of the following 6 criteria are identified:
  1. Insufficient Energy Intake
  2. Weight Loss
  3. Loss of Muscle Mass
  4. Loss of Subcutaneous Fat  
  5. Localized or generalized fluid accumulation that may sometimes mask weight loss
  6. Diminished functional status as measured by hand grip strength

Notice that ALBUMIN and PREALBUMIN are NOT criteria for diagnosis


Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at

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