Sahran, Nur-Fazimah
(2015)
The quality of clinical diagnosis and procedure coding and risk factors for malnutrition among hospitalized geriatrics in Hospital Universiti Sains Malaysia.
Masters thesis, Universiti Sains Malaysia.
Abstract
Malnutrition is highly prevalent among hospitalized geriatrics. Unfortunately, the
identification, notification and clinical coding of malnutrition have been reported to
be inadequate. In order to place malnutrition in the focus of the healthcare system, it
is mandatory to assess the current practice and the quality coding for malnutrition to
improve the overall quality in healthcare services. Therefore, the objectives of this
study were; (1) to determine factors associated with malnutrition among hospitalized
geriatrics (2) to study the impacts of malnutrition on clinical outcomes (3) to explore
the completeness documentation of nutritional information and (4) to identify the
causes of coding issue for malnutrition. A cross-sectional study was conducted
among hospitalized geriatrics aged 60 years and above in Hospital USM. A total 130
participants were recruited in this study consists of 49 (37.7%) men and 81 (62.3%)
women. The nutritional assessments conducted were anthropometric measurement
and biochemical assessment coupled with standard nutritional screening and
assessment tools. A systematic reviewed on the medical records for nutritional
information and clinical coding was conducted once participant was discharged. Data
were analysed using SPSS version 20. Results revealed that 35.4% of participants
were malnourished according to standard reference Subjective Global Assessment
(SGA). Multivariate analysis demonstrated that malnutrition were significantly
associated with low BMI (p<0.001) and albumin (p<0.05), loss of appetite (p<0.001)
and surgical procedure (p<0.05). Malnourished geriatrics were found to have
significantly longer hospital stay, higher complication and readmission rate
compared to well-nourished geriatrics (p<0.05). The documentation of weight was
48.5%, height; 27.7%, weight loss; 3.1%, dietary intake; 43%, loss of appetite;
11.5% and digestion problem; 32.3%. Only 50% of malnourished were intervened.
None of the participants had been diagnosed and coded with malnutrition. The causes
of coding issue for malnutrition were; lack of awareness among healthcare
professional (50.0%) and incomplete medical documentation (50%) at the ward
level. In addition, two causes were occurred for diagnosis and procedure coding;
uncoded (52.2%), miscoding diagnosis (39.1%), missing diagnosis code (8.7%),
missing procedure codes (26.7%), and unavailable codes for dietary counselling and
oral nutritional supplementation (73.3%). In conclusion, the quality of clinical coding
of malnutrition is mooted to be improve. Structured assessment and standard
documentation of malnutrition will allow optimization of this information to be used
in improving patient care management and quality of healthcare services
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