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).
|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.
Download the complete tip, Deep Tissue Injury.