Documenting malnutrition is important to gain better healthcare outcomes. This article examines this and the key documentation elements.

1. The Importance of Proper
Malnutrition Documentation
Documenting malnutrition is important to gain better healthcare outcomes.
This article examines this and the key documentation elements.
Medical Transcription Services

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Malnutrition diagnoses and their accurate documentation is important for providing
quality care. The nutritional status may be a sign of a more serious condition. Many
serious conditions including pancreatic cancer, lung cancer, head and neck cancer,
gastrointestinal cancer, stroke and chronic obstructive pulmonary disease (COPD) have a
high prevalence of associated malnutrition. Evaluating nutritional status during
hospitalization and up-to-date documentation is very important, especially when the
patient is hospitalized after surgery. Patients can develop malnutrition as a result of
anorexia, iatrogenic starvation (for tests, anesthesia), inadequate attempts during oral
feeding and prolonged ventilator support.
A recent review published in the Nutrition in Clinical Practice (NCP), a peer-reviewed,
interdisciplinary Journal of the American Society for Parenteral and Enteral Nutrition
(A.S.P.E.N.) reveals that proper documentation of malnutrition diagnoses in the hospital
can maximize patient care and reimbursement. Accurate documentation helps the
healthcare teams classify a patient’s degree of malnutrition and determine how
frequently they should reassess that patient’s response to care to ensure the best
possible care. The review states that the major funding source for most hospitals in the
United States is Medicare and the hospitals receive the payments through the Acute
Care Hospital Inpatient Prospective Payment System, which classifies patients into
Medical Severity Diagnosis-Related Groups (MS-DRGs) to take decision regarding
payment amounts. With the proper documentation of co-morbidities and complications,
the payment received by hospitals can be increased to offset patient care costs.
In short, lack of appropriate malnutrition documentation prevents patients from
receiving the care that they need by allowing hospitals to overlook malnutrition and
come up with inaccurate diagnoses. This will also cause hospitals to miss out on the
insurance payment they require to support the care of the patient.
Crucial Elements in Malnutrition Documentation
According to the American Society of Parenteral and Enteral Nutrition (ASPEAN), adult
malnutrition is diagnosed based on the presence of two or more of the following
characteristics such as:
 Inadequate energy intake
 Loss of weight
 Loss of muscle mass
 Loss of subcutaneous fat

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 Accumulation of localized or generalized fluid
 Weakened functional status as measured by the strength of hand grip
Physicians should mention those characteristics in their documentation to ensure
quality care. The key elements to include in malnutrition documentation are as follows:
 History and Clinical Diagnosis – The patient’s history and the diagnosis details
should be mentioned in your documentation. This will be helpful to suspect
conditions that may be associated with the inflammatory processes and
nutritional imbalance.
 Clinical Signs and Physical Examination – The clinical signs for inflammation
include the indicators associated with systemic inflammatory response
syndrome such as fever or hypothermia, tachycardia and tachyhypnea. Physical
examination may help identify fluid accumulation and the signs of weight gain or
loss.
 Anthropometric Data – This information includes body composition metrics such
as height, weight (particularly being underweight), history of weight loss,
characteristics of skin folds and circumference.
 Laboratory Indicators – Though laboratory indicators like variations in hepatic
proteins (low albumin or prealbumin) may not accurately measure nutritional
imbalance, they are helpful in indicating morbidity and mortality. Laboratory
indicators also include inflammation markers such as elevated C-reactive protein,
elevated or low white blood cell count, and elevated glucose. More complex
markers such as negative nitrogen balance and elevated metabolic rates can be
also mentioned under laboratory indicators.
 Dietary Data – This includes a modified diet history or a 24-hour diet recall of the
patients. Usually, patients are given a form to complete and it is analyzed by a
computer-based nutritional assessment program. However, this single sample
may not be the reflection of a patient’s typical intake. Therefore, it is not a good
idea to use the data as the sole assessment.
 Functional Outcomes – An assessment of strength and physical performance
and other associated findings should be mentioned under this section.

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An electronic health record (EHR) system will help to expedite the documentation
process as it allows you to copy and paste information and abbreviate (for example,
SPCM for severe protein calorie malnutrition). However, there is a greater chance for
users to enter wrong details inadvertently if they copy and paste information without
checking the content. Moreover, the reader of the malnutrition documentation may not
have access to the approved abbreviation list of the hospital or there may be no
approved abbreviation list for the hospital. This may cause the reader to misinterpret
the abbreviation and lead to poor outcomes. Effective communication among the
interdisciplinary team is very important as it can help physicians and team members
understand what the dietician has identified and the suggested care plan.
A combined approach of EHR and transcription can give you complete and accurate
malnutrition documentation. In this approach, skilled and experienced transcriptionists
transcribe the physician recordings and the transcribed data is populated into
corresponding fields within the electronic record system. Professional transcription
companies employ a dedicated quality assurance team to check whether the transcribe
data is accurate before sending it to the electronic record system. In this way, you can
ensure all the data within your documents is accurate and reliable.