A person who suffers a deficiency of the nutrients required for good health is said to be malnourished. While it is more common in developing countries, malnutrition is also a problem among children and adults in the United States. According to the Child Welfare League of America, more than 30 million Americans experience hunger regularly or are at risk of going hungry. Severe cases of malnutrition are treated in hospitals and research shows that proper documentation of patient malnutrition is crucial for proper diagnosis, care and reimbursement. Medical transcription plays an important role in this context.
For evaluation, documentation and management of nutrition and malnutrition, a collaborative approach involving physicians, nurses, and registered dietitians is recommended. A review published last year in Nutrition in Clinical Practice (NCP), a peer-reviewed, interdisciplinary journal of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) reported that nutrition support professionals can help a hospital ensure proper documentation of malnutrition diagnoses. These guidelines recommend that diagnosis of adult malnutrition be based on one of the following characteristics
- insufficient energy intake
- weight loss
- loss of muscle mass
- loss of subcutaneous fat
- localized or generalized fluid accumulation. And
- diminished functional status as measured by hand grip strength
Clinical history and symptoms are usually the major determinants of the condition and diagnostic tests and imaging studies may be needed to rule out underlying medical conditions that caused the malnourished state. Proper clinical documentation would include the following:
- History and clinical diagnosis
- Clinical symptoms and physical examination
- Body composition metrics
- Laboratory indicators
- Dietary data
- Details on assessment of strength and physical performance, etc.
Recent research indicates that nutrition support clinicians need to work on developing a valid and reliable program to identify, document, intervene, and code malnutrition. This will improve care as well as payments to the hospital. By classifying patients’ state of malnutrition, these specialists can help the healthcare team determine how often each patient would need reassessment and also their response to care, which in turn, will ensure the best possible outcomes.
To conclude, proper documentation of patient malnutrition is crucial to ensure effective care and also maximize reimbursement for the health care provider. When it comes to maintaining accurate medical records, the majority of hospitals now adopt an approach that blends EHR data entry and medical transcription outsourcing. While new technology and workflows have changed the way patient care data and the physician dictation is captured, the role of the medical transcriptionist in the creation and editing of health care documentation in compliance with HIPAA rules continues to endure.