SHM Converge Scientific Abstract ePoster Gallery-A Novel Electronic Tool for Malnutrition Documentation

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This study evaluated whether introducing and publicizing a non-interruptive electronic malnutrition documentation support tool would reduce documentation queries without reducing diagnostic coding at Johns Hopkins Hospital.<br /><br />The project used a single-site pre/post design with 1,200 hospital discharges of patients with dietitian-confirmed malnutrition: 600 before the intervention and 600 after. The tool was designed to help providers document malnutrition more accurately and efficiently using discrete data, especially in progress notes and discharge summaries.<br /><br />The main findings were:<br /><br />- Malnutrition documentation queries dropped by 63% after the tool was introduced.<br />- Malnutrition diagnostic coding did not decrease, suggesting the intervention improved documentation efficiency without harming coding capture.<br />- In the post-intervention sample, most queried discharges were not adherent to the tool’s intended use, meaning providers often did not use the tool within 48 hours after the dietitian assessment.<br />- A mixed-effects logistic regression found a strong reduction in the odds of a query in the post-intervention period versus pre-intervention period: OR 0.21 (95% CI 0.16–0.29, p<0.001).<br /><br />The study population was similar across periods, with median age around 61 years and a slight majority of male patients. Most patients had malnutrition present on admission, and the cohort included both moderate and severe malnutrition.<br /><br />Overall, the intervention appeared to improve malnutrition documentation by reducing the need for clarification queries, while maintaining diagnostic coding. The authors suggest that adherence may improve over time as providers become more familiar with the tool, and they highlight the potential of non-interruptive decision support to reduce workflow disruption and possibly help address burnout.

Asset Subtitle

Kevin W. O'Malley

Meta Tag

Author List Kevin W. O'Malley, Stephen A. Berry

Category Research

Concept Electronic Documentation Support Tool

Concept Malnutrition Documentation

Concept Non-interruptive Clinical Documentation Tool

Concept Malnutrition Documentation Queries

Concept Diagnostic Coding

Distinguished Non-Finalist

Presenter Organization Johns Hopkins Hospital

Presenting Author Kevin W. O'Malley

Track Technology in Hospital Medicine

Keywords

malnutrition documentation

electronic support tool

documentation queries

diagnostic coding

Johns Hopkins Hospital

non-interruptive decision support

pre post study

hospital discharge

dietitian-confirmed malnutrition

workflow efficiency

Electronic Documentation Support Tool

Malnutrition Documentation

Non-interruptive Clinical Documentation Tool

Malnutrition Documentation Queries

Diagnostic Coding