Documenting Malnutrition: Food for Thought

It’s that magical time of year for parents everywhere: back-to-school time. With a return to school comes a flurry of activity and planning and, in addition to obtaining school supplies and new clothes, parents must begin figuring out what their kids are going to eat for lunch.

Whether that lunch is going to be in a brown bag or from the lunch counter, parents want at least some assurance that what their kids are eating mid-day is nutritious – which brings me to the topic of malnutrition and documentation.

Hospitals employ deep benches of professionals to monitor and address patients’ nutritional statuses: from the cooks and servers in the kitchen, to the dieticians, to the pharmacy representatives who prepare total parenteral nutrition (TPN), to the techs and aides who help feed the patients, to the nurses who run the TPN, to the physicians who write the orders.

Yet descriptions and details of patient nutritional status are often lacking in documentation. I recently was reviewing an oncology case in which the physician described sudden and significant weight loss and the patient’s overall refusal to eat. Dietary was consulted. Appetite stimulants were ordered. The patient had a body mass index (BMI) of less than 19. Muscle wasting was described. The physician even surmised that the patient would die soon – probably from starvation rather than the cancer diagnosis.

All sorts of descriptions were found outlining how ill and poorly fed the patient appeared, but the only diagnosis documented was “the patient suffers from protein calorie malnutrition.”

On the flip side of the coin, I have seen plenty of charts that included a diagnosis of “severe protein calorie malnutrition,” but no dietary or nutritional consult. A general diet is ordered. The physical assessment makes no reference to a malnourished appearance or muscle or tissue wasting. The BMI is unremarkable. No weight loss is described. And no quantification of “severe” malnutrition is described.

I have done numerous presentations on inpatient denials and I almost always include a section on malnutrition. Diagnoses of malnutrition are often on the radar for third-party auditors, both because of their ability to move a DRG and because there is frequently poor documentation supporting assigned severity.

My advice to physicians is to document the severity of malnutrition that, in your professional opinion, is accurate, whether mild, moderate, or severe, but please remember the gravity of this diagnosis and make efforts to provide supporting documentation for whichever severity you document.

My advice to clinical validators, whether those in clinical documentation integrity (CDI), clinical auditing, or otherwise, is to continue to promote congruence between the documentation, the diagnoses, and the clinical indicators.

Regardless, every patient has a nutritional status, and not surprisingly, it is often clinically significant. Keep that in mind.

And that, they say, is food for thought.