Kevin O'Malley, Patricia Dasch, Sarah C Bauer, Dhananjay Vaidya, Matthew Severson, Sam Sokolinsky, Patricia Kaehne, Peter M Hill, Daniel J Brotman, Benjamin Erwin Bodnar, Stephen Lichtenstein, Renee Demski, Stephen A Berry
{"title":"Noninterruptive tool to support provider malnutrition documentation and minimize documentation queries.","authors":"Kevin O'Malley, Patricia Dasch, Sarah C Bauer, Dhananjay Vaidya, Matthew Severson, Sam Sokolinsky, Patricia Kaehne, Peter M Hill, Daniel J Brotman, Benjamin Erwin Bodnar, Stephen Lichtenstein, Renee Demski, Stephen A Berry","doi":"10.1093/jamiaopen/ooaf034","DOIUrl":null,"url":null,"abstract":"<p><strong>Objectives: </strong>Determine if an electronic documentation tool can reduce documentation queries for malnutrition without impacting diagnostic coding.</p><p><strong>Materials and methods: </strong>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.</p><p><strong>Results: </strong>Documentation queries for malnutrition were observed in 300 (50%) of the preintervention discharges and 112 (19%) of the postintervention discharges (<i>P</i> < .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.</p><p><strong>Conclusions: </strong>We have demonstrated that introducing and promoting this electronic documentation tool can reduce querying for malnutrition while preserving diagnostic coding.</p>","PeriodicalId":36278,"journal":{"name":"JAMIA Open","volume":"8 3","pages":"ooaf034"},"PeriodicalIF":3.4000,"publicationDate":"2025-05-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12093316/pdf/","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"JAMIA Open","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.1093/jamiaopen/ooaf034","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2025/6/1 0:00:00","PubModel":"eCollection","JCR":"Q2","JCRName":"HEALTH CARE SCIENCES & SERVICES","Score":null,"Total":0}
引用次数: 0
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.
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