Wednesday, February 8, 2017

Documenting Malnutrition Part 3

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

Chronic disease is frequently associated with malnutrition Examples of this are cancer, liver disease, malabsorption syndromes, heart failure, etc. In these cases, the process that ends in a patient being hospitalized is an acute problem such as an infection or an acute dysfunction of an organ system. The malnutrition is in the background, predisposing the patient to a worse outcome.  When these situations occur, the weight loss, the decline in appetite and the physical changes in the patient’s body are not taken into account by the patient or the family when they refer the history. Questioning properly becomes very important. The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines states that in order to consider a patient having severe malnutrition in the setting of chronic illness, he or she has to consume less than 75% of the estimated energy requirement for at least 1 month. 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 chronic illness, the loss of weight in 1 month has to be 5% or more. If the loss of weight happens in 3 month, it has to be 7.5% or more, if it happens in the preceding 6 months it has to be 10% or more and if it occurs in 1 year it has to be at least 20%

So, an HPI may read like this:

“Mrs Y is a 53 year old  lady who presented to the emergency department (ED) with a history of nausea, vomiting and diarrhea for 1 day. She was diagnosed with Crohn’s disease 5 years ago and in the past year she has had several flares. As an average, for the past month she has eaten only 50-70 % of her normal meals due to bloating and lack of appetite. In the past 6 months she has lost 15 pounds. She used to weigh 125 pounds. She presented to the ED because she was unable to keep any oral intake and she started to note a darker urine and a decrease in its volume”

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 December 13, 2016

Marco A. Ramos MD
Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement