Deep Tissue Injury

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Pressure and non-pressure ulcers and deep tissue injuries should be documented in a timely fashion and using specific language (i.e., Present on Admission, when appropriate).

Pressure Non-pressure
Stage 1 – non-blanching erythema of intact skin Skin breakdown
Stage 2 – abrasion, blister, partial thickness skin loss with exposed epidermis/dermis Exposed fat
Stage 3 – full thickness skin loss involving damage or necrosis of subcutaneous tissue Muscle necrosis
Stage 4 – necrosis of soft tissues through to underlying muscle, tendon or bone Bone necrosis
Unstageable – obscured, full thickness skin and tissue loss, depth unknown Unstageable
Cannot be determined Cannot be determined

Present on Admission
CRITICAL documentation element: Skin ulcers that are not Present on Admission are considered complications of hospital care.

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