Thursday, January 12, 2017

Documenting Malnutrition. Part 2

The History of Present Illness (HPI) in Severe Malnutrition in the Setting of Acute Illness

Documenting malnutrition, specially in the acute setting is one of the most disregarded aspects in clinical documentation. Many acute disease processes that lead to hospitalization, are preceded by a reduction in the intake of food and/or loss of weight. For example, a patient who is diagnosed with pneumonia with septic shock, could have started the process one week prior to the admission with an upper respiratory tract infection and with loss of appetite. Due to the decline in oral intake, the patient could have lost some weight and some patients may track their own weight or there might be outpatient records showing previous weights when the patient was not having the acute illness. The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines state that to consider a patient having severe malnutrition in the setting of acute illness, a reduction of more than 50% of the estimated energy requirement has to be present for 5 days or more. Since 2 criteria are needed, the requirement may be fulfilled by documenting weight loss or an aspect of the physical exam. Regarding the loss of weight criteria, ASPEN guidelines say that in order to consider a patient for having severe malnutrition in the setting of acute illness, the loss of weight in 1 week has to be 2% or more. If the loss of weight happens in a month, it has to be 5% or more and if it happens in the preceding 3 months it has to be 7.5% or more.

So, an HPI may read like this:

“Mr X is a 74 year old gentleman who presented to the emergency department (ED) with a history of 7 days of progressive productive cough, dyspnea, anorexia and fever. The patient referred that 7 days prior to presentation he developed “cold”. He said that his oral intake was reduced to about 25% of a normal meal. 3 days prior to admission, he developed productive cough with a green sputum and 2 days prior, high fever quantified at 102 F. Due to the symptoms getting progressively worse and the addition of dyspnea on mild efforts, he decided to show up in the ED. He stated that his usual weight is 150 pounds and now he is weight 145 pounds.”

Please note that the last piece of information can also be placed in the Review of Systems (ROS). The information in the HPI anticipates what is going to show in the Assessment and Plan (A/P)


1 Retrieved January 12, 2017

Marco A. Ramos MD
Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement

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