The discussion of the use of abbreviations continues to surface in hospitals nationwide. The most recent discussions we have had are in relationship to malnutrition. Documentation of malnutrition is one piece of the care of malnutrition. A hospitals focus on the care of malnutrition is like casting a net into the sea, reeling it in and finding so much more than fish.
Ensuring appropriate documentation when caring for malnutrition is very important. Without this documentation a patient may not receive the care they need and the hospital may miss out on an accurate diagnosis and insurance reimbursement to support the care of the patient.
With the use of electronic health record (EHR) it is very easy to copy and paste information and to abbreviate. In the world today, we communicate more than ever through emails, text messages, tweets, postings, blogs, and sometimes the phone. But overall communication is lacking. Writing has gone by the wayside. We, the world, communicate using emoji’s, abbreviations, and SMS (short message service) slang via text and now we are seeing this type of “language” in the professional setting. It’s now seen as an inconvenience to spell words out, it takes too much time! So how does that effect the day to day work in the EHR?
Let’s look at this example. A dietitian documents the following in their nutrition assessment note:
“SPCM related to inability to shop for and prepare food, early satiety and trouble breathing secondary to CHF as evidence by…” Then a physician documents: “Patient presents with SPCM.”
Does it matter if the clinician writes SPCM or severe protein calorie malnutrition? Won’t it get coded the same ICD-9 code either way?
We asked our colleague and expert in EHR documentation and coding, Sandy Routhier, RHIA, CCS, AHI to provide us with some expert guidance.
“It would be best to have severe protein calorie malnutrition spelled out at least once in the medical record. Anyone (clinician, coder, auditor, etc.) reviewing the medical record may not make the connection that “SPCM” is severe protein calorie malnutrition or they may misinterpret the meaning of the abbreviation. Additionally, the reader of the medical record documentation may not have access to the hospital’s approved abbreviation list or the hospital may not even have an approved abbreviation list. Accrediting agencies such as the Joint Commission (TJC) no longer require hospitals to have an approved abbreviation list – they only require a list of banned/unsafe abbreviations.
I recall a case I was auditing that had 263.9 (unspecified malnutrition) coded without supporting clinical evidence of a nutrition-related diagnosis. The diagnosis code of 263.9 was the only comorbidity (CC) that impacted the MS-DRG. Upon review of the medical record I found that the physician had documented “PCM” throughout the medical record therefore 263.9 ended up being coded. It turned out that the physician was using “PCM” as an abbreviation for primary cardiomyopathy.”
Effective communication is of utmost importance for the interdisciplinary team. It can help the physician and team members see what the dietitian has identified and their care plan. Take a look at the way you and your team are documenting. Are their abbreviations you are using that others in your hospital may not know the meaning? Does your EHR documentation need to be changed or updated to ensure correct documentation of the information you provide so that communication is achieved? Is the reason behind abbreviating to save time? Do you know your hospitals list of abbreviations?
When documenting malnutrition, from a nutritional or medical diagnosis, always spell it out! This will help communicate to all team members the true diagnosis. Communication = understanding.
Michelle Hoppman, RDN, LRD, CDE
Director, Nutrition Division
Executive Success Coach
Sandra Routhier, RHIA, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer
HIM & Coding Consultant