Diagnosing and Documenting Malnutrition

by Nadia Pshonyak, RD, LD and Ashley Cheryholmes, RD, LD

It is estimated that malnutrition is prevalent in more than 50% of hospitalized patients and is associated with higher healthcare costs, length of stay, and increased morbidity and mortality. Until recently, no universal definition of malnutrition was available, resulting in inconsistencies in diagnosing malnutrition. In order to standardize diagnosis and documentation of malnutrition, The Academy of Nutrition and Dietetics (Academy) and the American Society of Enteral and Parenteral Nutrition (ASPEN) developed a consensus statement in 2012 that identified adult malnutrition as “an acute, subacute, or chronic state of nutrition, in which a combination of varying degrees of overnutrition and undernutrition with or without inflammatory activity have led to a change in body composition and diminished function.”

ASPEN/Academy criteria utilize an etiology based approach to diagnose malnutrition which incorporates the role of the inflammatory response on malnutrition.  Inflammation is defined as an increased concentration of inflammatory mediators.  The inflammatory response can be acute or chronic. The presence of inflammation can increases the risk for or worsen the severity of malnutrition. In acute illness or injury there is decreased response to nutrition interventions and potentially increased mortality. Therefore, early nutrition interventions play a big role in improving patient outcomes.

After determining the etiology of malnutrition, 6 standardized diagnostic characteristics are used to identify the severity of malnutrition. These include: insufficient energy intake, unintentional weight loss, loss of body fat, loss of muscle mass, fluid accumulation, and diminished functional capacity. To diagnose malnutrition, two or more of these characteristics must be present.  Malnutrition is then identified as moderate, or severe.

The process of diagnosing malnutrition starts with identification of a patient at nutritional risk using a standardized screening tool.  Examples of common screening tools being used today include: Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), and The Nutrition Risk in Critically ill (NUTRIC). It is recommended that the malnutrition screening tool be appropriate for the patient population being served. Screening is required by The Joint Commission to identify patients at nutrition risk and should be completed by a trained clinician within 24 hours of admission to the hospital.  Patients identified at risk are then referred to the dietitian for assessment.
 
Once the RD receives a referral for an at risk patient, a full nutrition assessment is completed. The RD will review the patient’s anthropometrics, intake, weight history, medical history, labs, medications, diet orders and conduct a nutrition focused physical examination. After the RD has fully assessed the patient, a nutrition diagnosis can be made. 

Once the dietitian has determined the etiology and degree of malnutrition and has documented it in the medical record, a Licensed Independent Practitioner (LIP) should be notified to document malnutrition in their note. If the RD has provided written documentation about malnutrition, but provider has not added it also as a medical diagnosis, then the billing specialist may query the provider/LIP to obtain agreement with the dietitian’s documentation. Billing specialist may also follow up with the dietitian for documentation clarification. Providers must always include an intervention for each diagnosis. For malnutrition, the plan can simply be to consult the dietitian, refer to the dietitian note, or provide supplements and/or nutrition support.

Identifying and documenting malnutrition in hospitalized patients is important to improve patient outcomes, reduce length of stay, healthcare costs, and the risk for morbidity and mortality. Each hospital should put forth their own policies and procedures for identifying and documenting malnutrition based on evidence based guidelines as determined by their multidisciplinary team. Overall, establishing the presence and degree of malnutrition should be a collaborative process.

ABOUT THE AUTHORS

Nadia Pshonyak is a Registered Dietitian and has been working with the Cleveland Clinic Healthy System for over six years. She got her B.S. in Nutrition and Dietetics from the University of Akron in 2011. Nadia is a member of the Malnutrition Committee and is actively involved in a malnutrition initiative to educate dietitians and other healthcare professionals about diagnostic criteria for malnutrition.

Ashley Cherryholmes has been a Registered Dietitian for 5 years. She graduated from The University of Akron in 2013 with a B.S in Nutrition and Dietetics. She has been with Cleveland Clinic Healthy Systems for over 4 years.