Decubitus Ulcers

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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.