August 2013
Clinical Documentation Implementation

Improving clinical quality is the focus of the Yale New Haven Health System Cost/Value Initiative. To help keep that top of mind, Mahfuz Hoq, MD, Medical Director, Care Coordination, offers the following clinical documentation implementation tips:

DIAGNOSING MALNUTRITION:The American Academy of Nutrition and Dietetics and the American Society for Parental and Enteral Nutrition state that malnutrition should be diagnosed when providers identify at least two or more of the following six characteristics:

  • Insufficient energy intake
  • Weight loss
  • Loss of muscle mass
  • Loss of subcutaneous fat
  • Localized or generalized fluid accumulation that may sometimes mask weight loss
  • Diminished functional status as measured by hand grip strength

Providers must assess these in the context of an acute illness or injury, a chronic illness or social or environmental circumstances to determine if malnutrition is present and whether it’s severe or non-severe (moderate).

CODING HEART FAILURE:To correctly code the documented diagnosis of heart failure, the provider must document the acuity (acute, chronic or acute on chronic) and the specificity (diastolic, systolic or combined).