Prevalence and Documentation of Malnutrition in Hospitals

Objectives: To determine the prevalence of malnutrition and whether the malnourished participants were being identified and documented as malnourished. To evaluate the impact of poor documentation on financial reimbursement to the hospital.

Subjects: Three hundred and twenty-four inpatients from a total of 690 randomly selected patients consented to participate in the study.

Design and setting: Subjective Global Assessment (SGA) was used to assess the nutritional status of inpatients. There were 1906 patients were admitted over a three-month period. Of these, 1860 were eligible and 690 were randomly selected from computer generated ward lists. The referral rate for nutrition intervention of malnourished participants was determined by viewing the patient medical records retrospectively. The Australian National Diagnostic Related Group (AN-DRG) of the malnourished subjects, not documented in the medical record as malnourished, were redetermined with the addition of the malnutrition code. The potential shortfall in financial reimbursement to the hospital was calculated by subtracting the average costing based on original AN-DRGs from the average costing based on the revised AN-DRGs.

Main outcome measures: Prevalence of malnutrition, levels of malnourished patients identified and documented, revenue losses under case payment system.

Statistical analyses: Logistic regression analyses were used to evaluate group differences in sex across