Clinical Documentation Tip: Malnutrition

By Nina Youngstrom

ECU Health in North Carolina developed this tip sheet to help ensure compliant malnutrition documentation and coding (see story, p. 1). Contact Vaughn Matacale, M.D., physician advisor group director at ECU Health, at vaughn.matacale@ecuhealth.org.

Clinical Documentation Tip: Malnutrition

In 2012, the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (ASPEN) published a consensus statement regarding the definition and documentation of malnutrition in adults.

The Academy/ASPEN recommends classification of adult malnutrition by etiology:

  • Starvation-related malnutrition

  • Chronic disease-related malnutrition

  • Acute disease or injury-related malnutrition

There is no single parameter that is definitive for adult malnutrition. Hence, ASPEN recommends that identification of:

Two or more of the following six characteristics are needed for the diagnosis of malnutrition:

  • Insufficient energy intake

  • Weight loss

  • Loss of muscle mass

  • Loss of subcutaneous fat

  • Localized or generalized fluid accumulation that may mask weight loss

  • Diminished functional status as measured by hand grip strength

Both the diagnosis and the degree of malnutrition must be documented by the provider treating the patient for it to be reported.

To establish the detailed criteria for malnutrition and establish a treatment plan, consult the dietitian; all dietitians at ECU Health are trained in nutrition-focused physical examination and measurement of hand grip strength.

Documentation that would prompt a query:

  1. No physician documented diagnosis after nutrition consult with recommended diagnosis of a specified malnutrition.

  2. Varying degrees of malnutrition documented in the progress notes. (Attending will get query to clarify.)

  3. Documentation of malnutrition without clinical indicators to support the diagnosis.

ASPEN criteria attached

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