Did you know? Decubitus ulcers have specific documentation requirements.
- Document the exact location of the ulcer.
- Document the stage of the ulcer.
- Stage 1: Non-blanchable erythema of intact skin
- Stage 2: Partial thickness skin loss involving epidermis, dermis or both
- Stage 3: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia
- Stage 4: Full thickness skin loss w/ extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (i.e.–tendons, joint capsule)
- Be sure to investigate for the presence of decubitus ulcers at the time of admission
- Remember to document both the location and the stage at the time of admission, if present
- Ulcers NOT documented as being Present on Admission count as Hospital Acquired Conditions (HACs) and are quality “red flags” that are tracked by CMS
Note: Staging of ulcers can be taken from nursing documentation if you document the ulcer exists.
Download the complete tip, Decubitus Ulcers.