Introduction: Detailed clinical information is important for the Casemix System to
generate valuable Case Based Group (CBG) for malnourished geriatric patients. Clinical
coding for malnutrition provides useful information on the nutritional health of patients
for treatment purposes.
Methods: This cross-sectional study with purposive sampling
involved a total of 130 geriatric patients (>60 years) at Hospital Universiti Sains Malaysia
(USM). Nutritional assessments were performed such as anthropometrics measurement,
Subjective Global Assessment (SGA), and biochemical assessment. The patients’ medical
records and coded data were systematically reviewed to observe the documentation of
nutritional information and coding criteria based on the International Classification for
Diseases (ICD-10).
Results: The prevalence of malnutrition among the geriatric patients
was 35.4%. Proper documentation of required nutritional information was found in less
than 50% of the cases. None of the malnourished patients were documented and coded
with malnutrition diagnosis, despite being given nutritional interventions. The reasons
given for this omission were related to the lack of awareness (50%) and incomplete
medical documentation (50%). Further analysis revealed that uncoded diagnosis,
miscoding, missing, and unavailable codes for nutritional counselling and oral nutritional
supplementation were the main contributors to the incomplete records.
Conclusion:
The quality of clinical coding for malnourished geriatric patients in the hospital should
be improved. A structured assessment and standard documentation is recommended to
improve the quality of healthcare provision for malnourished geriatric patients.