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Tips to Boost Your Documentation Process: Malnutrition

Posted on Wed, Sep 17, 2014
Tips to Boost Your Documentation Process: Malnutrition

Good documentation is important for new physicians as well as veteran caregivers. While documenting can seem like a very straightforward skill, there are often “best practices” that can be utilized. As a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL I write a “weekly documentation tip” email to help physicians improve their clinical documentation. I also share these documentation strategies with the residents I teach.

by: Timothy N. Brundage, M.D., CCDs

Malnutrition: Reducing Readmissions

  • Malnutrition should be diagnosed when two or more of the following six criteria are identified: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
  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

Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.

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