When a patient becomes sick enough to visit the emergency department, many times he or she has had an acute nutritional deficit that actually has made the situation worse. In addition to being severely malnourished, the patient could be having hypotension, septic shock, acute kidney failure or metabolic encephalopathy. Severe malnutrition is one the diagnoses that most commonly is not included in the documentation of the patients' conditions. On top of the fact that there has been a nutritional deficit, an additional criteria is required for the diagnosis of malnutrition (in all its degrees of severity). Edema, loss of muscle strengthweight loss, loss of muscle or adipose tissue or weakness could be used.

Marco A. Ramos MD, CCDS

In order to quote from this article please use the following:

Marco A. Ramos, “Clinical Documentation Improvement Series #11. If the Patient Has Not Eaten for Several Days Before Admission…”,” SMO Blog (blog), October 21, 2018, https://steemit.com/healthcare/@secondmedicalop/clinical-documentation-improvement-series-11-if-the-patient-has-not-eaten-for-several-days-before-admission

Links to the Previous Posts in this Series

- Clinical Documentation Improvement Series #1. Documenting Acute Respiratory Failure

- Clinical Documentation Improvement Series #2. How and When Do We Use the Body Mass Index (BMI)

- Clinical Documentation Improvement Series #3. Is it Delirium or Encephalopathy?

- Clinical Documentation Improvement Series #4. Documenting Myelopathies and Radiculopathies

- Clinical Documentation Improvement Series #5. Documenting Electrolyte Imbalances.

- Clinical Documentation Improvement Series #6. Documenting Electrolyte Imbalances.

- Clinical Documentation Improvement Series #7. Documenting Electrolyte Imbalances.

- Clinical Documentation Improvement Series #8. Documenting Electrolyte Imbalances.

- Clinical Documentation Improvement Series #9. Documenting Electrolyte Imbalances.

- Clinical Documentation Improvement Series #10. Documenting Electrolyte Imbalances.

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