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) guidelines¹  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)

References

1 http://www.baxternutritionacademy.com/ie/disease_related/identifying_malnutrition.html Retrieved January 12, 2017

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement

Vitamin D and Cancer

In a previous post from January 27, 2016  (http://blog1.smopinions.com/2016/01/7-interesting-facts-about-vitamin-d.html), it was mentioned that there are associations between vitamin D deficiency and certain types of cancer. This post will explain a little bit more about them.

Regarding colorectal cancer, it was noticed about 2 decades ago, that there is more mortality from colorectal cancer in the northern and northeastern parts of the United States, the ones which receive less sunlight. This in itself is not enough to establish a meaningful association, however, it gave a starting point for research. Then, 2 studies showed that having levels above 30 ng/dL in the blood may reduce the incidence of colorectal cancer by half^1,2.

With respect to breast cancer, a recent study found that postmenopausal women may get a benefit from having adequate vitamin D levels in the blood. The risk of developing breast cancer in this particular group of women was lower than in the same group of women with lower vitamin D in their blood³.

Finally, in regards to prostate cancer, it has been found that this cancer is also more common in regions with less sun exposure. In addition, lower vitamin D levels in the blood are related to more aggressive forms of prostate cancer. Last but not least, adequate levels of vitamin D may aid in the slowing of the progression of this type of cancer⁴.

More research is needed in order to confirm and strengthen these associations. In the mean time, it does not hurt to have adequate levels of vitamin D in the blood, particularly for people living north of the 30th parallel.

References

1. Serum 25-hydroxyvitamin D and colon cancer: eight-year prospective study. Garland CF, Comstock GW, Garland FC, Helsing KJ, Shaw EK, Gorham ED. Lancet. 1989;2(8673):1176-8.

2. Meta-analysis: longitudinal studies of serum vitamin D and colorectal cancer risk. Yin L, Grandi N, Raum E, Haug U, Arndt V, Brenner H. Alim Pharm Therap. 2009 30(2):113-25

3. Plasma vitamin D levels, menopause, and risk of breast cancer: dose-response meta-analysis of prospective studies. Bauer SR, Hankinson SE, Bertone-Johnson ER, Ding EL. Medicine (Baltimore). 2013;92(3):123-31

4. Association between serum 25(OH)D and death from prostate cancer. Tretli S, Hernes E, Berg JP, Hestvik UE, Robsahm TE. Br. J. Cancer 2009;100(3):450-4.

Marco A. Ramos MD

Documenting Malnutrition. Part 1

There are several types of malnutrition. There is protein malnutrition (kwashiorkor), calorie malnutrition (marasmus) and the combined protein calorie malnutrition. In our society, the most common form of malnutrition is the latter and it will be the one most used in the medical records. There are also several degrees of malnutrition, mild, moderate and severe) and they can be associated to an acute or a chronic process. The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines recommends that the diagnosis of malnutrition in the adult patient be supported by the presence of two or more of the following: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized edema, and decreased handgrip strength¹. The degrees of malnutrition can be seen in tables, available online² 

Properly documenting malnutrition requires to have the discipline of always including in the history of present illness (HPI) and review of systems (ROS) a nutritional history. A significant percentage of the disease processes that lead to an admission of a patient to the hospital include a problem with food intake or weight loss. In addition to this, the physical exam can enable us to describe the loss of muscle mass, the loss of subcutaneous fat, the presence of edema and the decreased handgrip strength. The assessment and plan (A/P) should include a nutritional diagnosis (if pertinent) and its chronicity, degree of severity and type.

Lastly, once the diagnosis is established, a plan to deal with it has to be formulated. This plan could be a dietitian consult, a gastroenterology consult for a feeding tube, an interventional radiology consult for TPN vascular access, to cite some examples.

References

1. White JV, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-738.

2. http://www.baxternutritionacademy.com/ie/disease_related/identifying_malnutrition.html Retrieved December 13, 2016

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement

Altitude Sickness. How to Avoid it.

Some of the most beautiful places in the world are situated in mountainous regions of the world. Many of these places are very popular places for tourism. The majority of travelers are not used to high altitudes. The atmospheric pressure at 10000 feet above sea level (3050 meters above sea level) is two thirds that of the one at sea level. This means that when traveling to such altitudes it is like one third of the atmosphere (and oxygen) has been removed.

Altitude sickness is characterized by headache, nausea, shortness of breath on exertion, tachycardia and fatigue. In very rare circumstances, it can cause pulmonary edema or cerebral edema. 

In order to avoid or minimize the symptoms of altitude sickness, the traveler from sea level has to take it easy. Upon arrival to the high altitude location, rest, walk slowly, and take deep breaths. The tourist must eat lightly and allow one or two days for proper acclimatization (getting used to the new environment). True acclimatization does not complete until 2 or 3 weeks, however, there is never so much time during vacation. A strategy that some travelers employ is to travel to the desired destination in a stepwise fashion, stopping in intermediate altitude towns prior to the arrival to the high altitude place.

Finally, there are medications that physicians are familiar with and that may help. Travelers should contact their respective doctor for this purpose.

Marco A. Ramos MD

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

What is Obstructive Sleep Apnea? Who is at Risk?

Obstructive Sleep Apnea (OSA) is a very common condition in which the upper airway gets obstructed by relaxed soft structures during sleep. This obstruction leads to inadequate air exchange in the lungs, increased diaphragm and chest wall muscle contractions as efforts to relieve the obstruction occur. In addition, OSA is characterized by poor sleep quality due to multiple brief periods of waking up during the night as the body moves and loud gasps happen. Finally, due the the poor sleep quality, daytime sleepiness is a feature of this condition, with all the problems this entrails.

There are certain groups of people who are at risk of having OSA. Obese or overweight individuals, patients with enlarged tonsils or large tongues, people with a thick or large neck or individuals who have upper airways with small diameters. The formal diagnosis of OSA is made with an overnight sleep study, however it can be strongly suspected if a person has daytime sleepiness, snores loudly and if there are visible episodes of “not breathing” (apnea) during sleep.

OSA can lead to elevated blood pressure, problems with attention and concentration, daytime sleepiness, irritability, and headaches. Treatment includes the avoidance of alcohol, sleeping on a side, use of a continuous positive air pressure (CPAP) device, surgery to remove extra tissue, and the use of an implantable upper airway stimulator. A primary physician will be able to refer someone who may have this condition to a local sleep specialist.

Marco A. Ramos MD

Tips For Great Clinical Documentation Part 4

In the previous post of the series, I highlighted the importance of being consistent when documenting, as the days pass and as the patient’s situation changes. In this post, I am going to mention how creating templates can help and how and why to avoid medical record cloning

Create templates, but avoid medical record cloning.

When providers see patients and document, a sequence of actions occurs that does not vary patient to patient. First the provider sees the record, the new laboratory workup, the past history, then, he or she sees the patient and finally the creation of a new note takes place. This last step also has its own sequence because all different types of notes have defined sections that have to be present for all cases. Creating templates for documentation helps with not forgetting to include the necessary elements of the history and physical, progress note, consultation, discharge summary, postoperative note, etc. In addition to that, a template can make the provider remember to include always certain aspects that may be missed, like a nutritional assessment, for example.

One of the abilities of  electronic health record systems is the ability of being able to import parts of a previous record into a new note. Some information may change little on a day to day basis. The ability of “cut and paste” can lead to medical record cloning if appropriate measures are not taken. Medical record cloning can lead to fraud, in the sense that a chart may contain information that may not represent exactly what happens to the patient in a particular day and and the same time lead to inaccurate billing. In order to avoid medical record cloning physicians using the “cut and paste” technique must make sure that the note is unique for the day, that it reflects what happened in that particular day and that billing is consistent with the content of the note.

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement