Achievements in Improving Documentation to Depict a More Accurate Clinical Representation of Patients with Malnutrition While Increasing Visibility of the RDN

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The purpose of this quality project was to improve the documentation of malnutrition diagnoses in the electronic health record (EHR) to represent more accurate depictions of patients' clinical conditions. It is imperative to identify, prevent and treat hospital malnutrition in order to provide high quality care for patients. Malnutrition diagnoses are often missed and are commonly queried by coders. Compared to those who are not, malnourished patients are more likely to have adverse outcomes such as: pressure injuries, falls, and delayed healing leading to longer stays and readmissions. Registered dietitian nutritionists (RDNs) are the experts who can provide low-risk, cost-effective interventions and engage the care team in efforts to provide high quality care for these patients. Work began at Spectrum Health (SH) in 2015 with a pilot study aimed at improving physician malnutrition diagnosing and documentation. RDNs worked with physicians to improve the process of documenting malnutrition. In January 2016, using the Malnutrition Quality Improvement Initiative (MQii) Toolkit, an executive-sponsored Malnutrition Steering Committee was initiated. The initial goal was to further improve the documentation of malnutrition diagnoses by RDNs and physicians. This required raising awareness around hospital malnutrition and the critical role of RDNs. It also required improving RDN performance of the Nutrition Focused Physical Exam (NFPE). In November 2017, enhancements were implemented to malnutrition documentation while switching EHR software platforms. RDNs collaborated with informatics specialists, providers, coders, and analysts to improve documentation processes. Malnutrition specific flowsheet rows and a malnutrition note were added to the EHR. The RDN completes the flowsheet rows in the Nutrition Assessment Flowsheet to efficiently and completely document the criteria that supports a malnutrition diagnosis found upon assessment and physical exam. These are then pulled into a Malnutrition Note that is routed to the physician for cosign. This provider signature is required for coding malnutrition diagnoses. RDNs were also granted privileges to add malnutrition diagnoses to the Problem List. Concurrently, RDNs were further trained on the NFPE and raised awareness of expertise. The number of documented cases by RDNs and providers in 2018 were compared to the number in 2016 to determine the impact of these changes. The number of documented malnutrition cases by RDNs in 2018 was 3895, up 270% from 2016 (1440). Enhancing RDN NFPE skills improved identification and documentation of malnutrition. The number of documented malnutrition cases by providers in 2018 was 1594 (Jan-May 2018), which was 7.2% of discharged patients in that time. This was up 239% from 2016 (667 between Jan-May 2016). Awareness efforts and EHR enhancements improved provider agreement with RDN diagnoses. RDNs began adding malnutrition diagnoses to the Problem List in the EHR in November 2017. RDNs are the only disciple other than providers granted these privileges at SH. This allows the malnutrition diagnosis to be addressed at each health care encounter. Improved documentation to represent a more accurate depiction of the clinical condition of patients with malnutrition was achieved. RDNs built interdisciplinary relationships while collaborating with other departments, which have elevated the RDN role in care and in decision making throughout the organization.