Incorporating current evidence-based best practice standards into clinical processes is critical to achieving excellent quality of care. That’s why Saratoga Hospital adopted recommendations from the Consensus Statement of the Academy of Nutrition and Dietetics and The American Society of Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) as standard criteria for adult malnutrition, diagnosis, and documentation.
A multidisciplinary team reviewed the guidelines and developed an implementation plan using the Plan-Do-Study-Act approach. The clinical nutrition team was trained on the new guidelines and a reference tool was created for their use. A new screening system identifies patients at risk of malnutrition, and revised electronic documentation templates identify a malnutrition diagnosis and the criteria that were used. Clinical documentation specialists review reimbursement for malnutrition diagnoses and help educate provider groups on the new criteria and improved process.
These improvements have resulted in early identification of malnutrition and timely interventions, which begin by day four of hospitalization instead of day seven to ten. More accurate and complete documentation, especially in the case of severe malnutrition, has positively impacted reimbursement.