Pressure Injuries Feb2019 Quest

Documenting Pressure Injuries
Below are helpful hints when documenting pressure injuries:
• Providers must state the following:

o Location of the pressure injury or injuries
o Whether the pressure injury is present on admission
o Stage of the pressure injury
▪ For coding purposes, staging information may be taken for the
wound nurse consult note.
Below are examples of documentation needed for coding pressure injuries from your
progress notes:
• Pressure injury: state location, stage, and present on admission (POA) status
• Pressure sore: state location, stage, and POA status
• Pressure wound: state location, stage, and POA status
• Deep tissue injury: state location, stage (or unstageable, if applicable), and POA
status
Remember that a DTI (deep tissue injury) may be related to a contusion, vascular
insufficiency, or a bruise appearing area. Please clarify and verify with the wound nurse
consult note when available for accurate documentation.
• Decubitus ulcer: state location, stage or unstageable, and POA status

• Bedsore: state location, stage, and POA status
Below are the four stages of pressure injuries and the depth of the skin they affect.
Stages of Pressure Injuries
The National Pressure Ulcer Advisory Panel provides the following definitions:
* This information was taken directly from the NPUAP website noted below.
Pressure Injury:
A pressure injury is localized damage to the skin and/or underlying soft tissue usually
over a bony prominence or related to a medical or other device. The injury can present
as intact skin or an open ulcer and may be painful. The injury occurs as a result of
intense and/or prolonged pressure or pressure in combination with shear. The tolerance
of soft tissue for pressure and shear may also be affected by microclimate, nutrition,
perfusion, co-morbidities, and condition of the soft tissue.
Stage 1 Pressure Injury: Non-blanchable erythema of intact skin

Intact skin with a localized area of non-blanchable erythema, which may appear
differently in darkly pigmented skin. Presence of blanchable erythema or changes in
sensation, temperature, or firmness may precede visual changes. Color changes do not
include purple or maroon discoloration; these may indicate deep tissue pressure injury.
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis

Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red,
moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is
not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are
not present. These injuries commonly result from adverse microclimate and shear in the
skin over the pelvis and shear in the heel. This stage should not be used to describe
moisture associated skin damage (MASD) including incontinence associated dermatitis
(IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or
traumatic wounds (skin tears, burns, abrasions).
Stage 3 Pressure Injury: Full-thickness skin loss
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation
tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may
be visible. The depth of tissue damage varies by anatomical location; areas of
significant adiposity can develop deep wounds. Undermining and tunneling may occur.
Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or
eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
Stage 4 Pressure Injury: Full-thickness skin and tissue loss

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle,
tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible.
Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by
anatomical location. If slough or eschar obscures the extent of tissue loss this is an
Unstageable Pressure Injury.
Unstageable Pressure Injury, obscured full-thickness skin and tissue loss

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer
cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is
removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry,
adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not
be softened or removed.
Deep Tissue Pressure Injury

Persistent non-blanchable deep red, maroon or purple discoloration
Intact or non-intact skin with localized area of persistent non-blanchable deep red,
maroon, purple discoloration or epidermal separation revealing a dark wound bed or
blood-filled blister. Pain and temperature change often precede skin color changes.
Discoloration may appear differently in darkly pigmented skin. This injury results from
intense and/or prolonged pressure and shear forces at the bone-muscle interface. The
wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve
without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia,
muscle or other underlying structures are visible, this indicates a full thickness pressure
injury (Unstageable, Stage 3, or Stage 4). Do not use DTPI to describe vascular,
traumatic, neuropathic, or dermatologic conditions.
Medical Device Related Pressure Injury (etiology)

Medical device related pressure injuries result from the use of devices designed and
applied for diagnostic or therapeutic purposes. The resultant pressure injury generally
conforms to the pattern or shape of the device. The injury should be staged using the
staging system.
Mucosal Membrane Pressure Injury

Mucosal membrane pressure injury is found on mucous membranes with a history of a
medical device in use at the location of the injury. Due to the anatomy of the tissue
these ulcers cannot be staged.
Please contact the Clinical Documentation Improvement Department with any
questions. Further education regarding this topic is available for your team through the
CDI department.
Jaime Sherman, CDI quality oversight specialist
[email protected] 319-356-3348
References:
National Pressure Ulcer Advisory Committee. (2019, Jan 7). NPUAP Pressure Injury Stages. Retrieved
from http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-
stages/

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Documenting Pressure Injuries

Below are helpful hints when documenting pressure injuries:

• Providers must state the following:

• Decubitus ulcer: state location, stage or unstageable, and POA status

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin

Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis

Stage 4 Pressure Injury: Full-thickness skin and tissue loss

Unstageable Pressure Injury, obscured full-thickness skin and tissue loss

Deep Tissue Pressure Injury

Medical Device Related Pressure Injury (etiology)

Mucosal Membrane Pressure Injury

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