Noninterruptive tool to support provider malnutrition documentation and minimize documentation queries.

OBJECTIVES

Determine if an electronic documentation tool can reduce documentation queries for malnutrition without impacting diagnostic coding.

MATERIALS AND METHODS

Malnutrition documentation queries and diagnosis coding proportions were compared between 2 groups of 600 malnourished adults discharged from internal medicine services before and after this electronic malnutrition documentation tool was promoted.

RESULTS

Documentation queries for malnutrition were observed in 300 (50%) of the preintervention discharges and 112 (19%) of the postintervention discharges ( < .001). A diagnosis code for malnutrition was observed in 99% of both groups. In a logistic regression accounting for clustering by provider, the odds ratio of a query postdeployment vs predeployment was 0.21 (95% CI, 0.16-0.29). In 88 of 112 (79%) of the postintervention discharges queried for malnutrition, the tool was not used as recommended.

CONCLUSIONS

We have demonstrated that introducing and promoting this electronic documentation tool can reduce querying for malnutrition while preserving diagnostic coding.