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Did You Know? Bedsore requirements from HIM

27 May 2018

Decubitus ulcers have specific documentation requirements

By: Karen Gray, RN CCDS

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Our clinical documentation team in HIM offers this reminder about documenting decubitus ulcers:

  1. Document the exact location of the ulcer.
  2. Document the stage of the ulcer.
  3. Be sure to investigate for the presence of decubitus ulcers at the time of admission.
    • 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 the underlying fascia.

    • Stage 4: Full thickness, skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures like tendons, joint capsules, etc.

  4. Remember to document BOTH the location and stage at the time of admission, if present. Any ulcers NOT documented as being Present on Admission count as hospital-acquired conditions that will be “red flags” for quality and tracked by CMS.
  5. Staging of ulcers can be taken from staff nurse or CWON documentation but you must document that the ulcer exists.  

Thanks for your cooperation!