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Noninterruptive tool to support provider malnutrition documentation and minimize documentation queries
Kevin O'Malley1, Patricia Dasch2, Sarah C Bauer3
1Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, United States.
Objectives:
Determine if an electronic documentation tool can reduce documentation queries for malnutrition without impacting diagnostic coding.
Materials And Methods:
Malnutrition documentation queries and diagnosis coding proportions were compared between 2 groups of 600 malnourished adults discharged from internal medicine services before and after this electronic malnutrition documentation tool was promoted.
Results:
Documentation queries for malnutrition were observed in 300 (50%) of the preintervention discharges and 112 (19%) of the postintervention discharges (P < .001). A diagnosis code for malnutrition was observed in 99% of both groups. In a logistic regression accounting for clustering by provider, the odds ratio of a query postdeployment vs predeployment was 0.21 (95% CI, 0.16-0.29). In 88 of 112 (79%) of the postintervention discharges queried for malnutrition, the tool was not used as recommended.
Conclusions:
We have demonstrated that introducing and promoting this electronic documentation tool can reduce querying for malnutrition while preserving diagnostic coding.
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