SHM Converge Scientific Abstract ePoster Gallery-Improving Documentation and Capture of Malnutrition

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This project aimed to improve identification and documentation of malnutrition among adult inpatients at UNMH, where malnutrition had been severely underdiagnosed compared with national inpatient rates. In 2014, only 4.7% of inpatients were discharged with a malnutrition diagnosis, suggesting missed cases in a population with substantial poverty and nutritional risk.<br /><br />An interdisciplinary process improvement team introduced several interventions over time: a consensus guideline to align coding and documentation, a dietitian documentation guideline, revised nursing nutrition screening with dietary consult triggers, staff training on malnutrition communication, and later a 2022 workflow allowing dietitians to enter malnutrition diagnoses and supporting text directly into the chart for auto-import into discharge summaries.<br /><br />Using adult inpatient encounters from January 2018 through June 2022, the team evaluated changes in malnutrition coding and documentation. Provider discharge summary documentation improved over time, increasing from 60% in late 2019 to 64% in late 2021 and 71% after the new 2022 process. Auto-import tools also helped, with discharge summary documentation rates ranging from 14% to 24% during the first few months after implementation. Overall malnutrition coding increased from 4.7% in 2014 to 7% for any malnutrition diagnosis in 2022, and severe malnutrition coding increased from 1% to 4.5%.<br /><br />The authors concluded that process improvements increased malnutrition documentation and coding, but rates still remained below expected national levels, indicating continued underdiagnosis. They noted this may lead to underestimated mortality, distorted mortality metrics, and lost revenue. Future goals include hiring more dietitians, making the nursing malnutrition screen mandatory, improving screening triggers, and standardizing discharge templates.

Asset Subtitle

Johnathan Jensen

Meta Tag

Author List Anthony Worsham, Jens Langsjoen, Johnathan Jensen, Joshua Marquez, Julia Howard, Scott Jun

Category Innovations

Concept Malnutrition

Concept Malnutrition Screening

Concept Documentation

Concept Patient Outcomes

Concept Mortality

Distinguished Non-Finalist

Presenter Organization University of New Mexico School of Medicine

Presenting Author Johnathan Jensen

Track Quality Improvement

Keywords

malnutrition

adult inpatients

documentation

coding

underdiagnosis

dietitian

nutrition screening

discharge summary

process improvement

hospital quality improvement

Malnutrition

Malnutrition Screening

Documentation

Patient Outcomes

Mortality