Noninterruptive tool to support provider malnutrition documentation and minimize documentation queries

Authors

Kevin O'Malley, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, United States.
Patricia Dasch, Department of Clinical Documentation Excellence/Casemix, Johns Hopkins Health System, Baltimore, MD 21287, United States.
Sarah C. Bauer, Department of Clinical Nutrition Education and Practice, Johns Hopkins Health System, Baltimore, MD 21287, United States.
Dhananjay Vaidya, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, United States.
Matthew Severson, Department of Revenue Management and Reimbursement, Johns Hopkins Health System, Baltimore, MD 21287, United States.
Sam Sokolinsky, JHHS Quality and Clinical Analytics, Johns Hopkins Hospital, Baltimore, MD 21287, United States.
Patricia Kaehne, Department of Clinical Documentation Excellence/Casemix, Johns Hopkins Health System, Baltimore, MD 21287, United States.
Peter M. Hill, Office of Medical Affairs/Chief Medical Officer, Johns Hopkins Health System, Baltimore, MD 21287, United States.
Daniel J. Brotman, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, United States.
Benjamin Erwin Bodnar, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, United States.
Stephen Lichtenstein, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, United States.
Renee Demski, Rochester Regional HealthFollow
Stephen A. Berry, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, United States.

Department

Quality and Patient Safety

Document Type

Article

Publication Title

JAMIA Open

Abstract

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 (P < .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.

First Page

ooaf034

DOI

10.1093/jamiaopen/ooaf034

Volume

8

Issue

3

Publication Date

6-1-2025

PubMed ID

40401005

Recommended Citation

O'Malley, K., Dasch, P., Bauer, S. C., Vaidya, D., Severson, M., Sokolinsky, S., Kaehne, P., Hill, P. M., Brotman, D. J., Bodnar, B. E., Lichtenstein, S., Demski, R., & Berry, S. A. (2025). Noninterruptive tool to support provider malnutrition documentation and minimize documentation queries. JAMIA Open, 8 (3), ooaf034. https://doi.org/10.1093/jamiaopen/ooaf034