Documenting Obesity

Obesity is defined by having a body mass index (BMI) of 30 or more. For clinical purposes, the BMI is a screening tool, however, for the purposes of documenting in a patient’s chart it is very important  to make the difference between people who have obesity and people who do not. Continuing with definitions, morbid obesity is when someone has a BMI of 40 or more. 

Obesity is very common in our society. For this reason, it tends to be overlooked and not included in the patient’s chart when documenting. In addition, many physicians feel uncomfortable including  diagnosis that may make the patient not feel good about him or herself. Obesity and specially morbid obesity, are associated with increased morbidity and mortality by worsened outcomes and delayed recovery times. Hospitals use more resources when treating patients who are obese or morbidly obese.

In order to make sure obesity and morbid obesity are properly documented, providers have to develop the habit of including a BMI, close to the patient’s vitals. Moreover, providers should always allow in their templates a space for a nutritional diagnosis.

Finally, its is extremely important to include the diagnosis of obesity hypoventilation syndrome if the patient has a BMI greater than 30 and also has a diagnosis of obstructive sleep apnea (OSA) or a documented wake up arterial partial pressure of carbon dioxide greater than 45 mmHg with no other cause such as chronic obstructive pulmonary disease  (COPD), asthma, or hypoventilation from other causes.

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement