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1 Documentation Tip of the Week: Decubitus Ulcer Documentation Did You Know? Decubitus ulcers have specific documentation requirements 1. Document the exact location of the ulcer 2. Document the stage of the ulcer: 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 underlying fascia Stage 4: Full thickness skin loss w/ extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures ( tendons, joint capsule).

2 Be sure to investigate for the presence of decubitus ulcers at the time of admission Remember to document both the location and the stage at the time of admission, if present o Ulcers NOT documented as being Present on Admission count as Hospital Acquired Conditions (HACs) and are quality red flags . that are tracked by CMS. Note: Staging of ulcers can be taken from nursing documentation if you document the ulcer exists All materials contained in this document are protected and the property of Brundage Medical Group, LLC, d/b/a Brundage Group, and may not be reproduced, republished, distributed, transmitted, displayed, broadcast or otherwise exploited in any manner without the express prior written permission of Brundage Group.

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