Clinical Documentation Tip: Malnutrition Documentation

When you find a query that includes clinical descriptions of nutritional status (Nutrition assessment, albumin, prealbumin, protein levels, treatment such as TPN, Ensure Megace and descriptors i.e. cachexia, anorexia and BMI < 19), Clinical Documentation RNs are inquiring if you are treating, monitoring and evaluating the diagnosis of malnutrition (protein/calorie) and are asking for that to be documented along with a degree of severity (mild, moderate or severe).