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.
Download the complete tip, Deep Tissue Injury.