Q&A: Pressure injuries when documented by nursing

Q: We’re having a lot of discussions lately on whether we should query for pressure injuries when they’re only documented by nursing. Our wound care nurses determined that staff nurses identify pressure injuries correctly only 60% of the time. If we’re querying based on nursing documentation, our administration is concerned that we’re running the risk of getting pressure injuries coded that are not truly pressure injuries. The physicians generally state they are not experts in staging and agree with the nursing wound care assessment.

What is your recommendation for pressure injury querying?

A: Identification of a pressure ulcer is a medical diagnosis, so before it can be staged and identified as a deep tissue pressure injury the provider must diagnose it as a pressure ulcer. Then we can obtain staging from nursing staff (stage 1, 2, 3, 4, unstageable, or deep tissue). Then, the provider MUST identify the etiology and the location of the wound.

All that said, query for the etiology from the provider—based on the patient’s history, location, and appearance of the wound, the provider can determine if it is a traumatic, non-healing surgical, non-pressure, chronic, or pressure ulcer. Once this determination is made, the nursing documentation can clarify the stage or the depth for the chronic ulcers.

Nurses should also receive education on identifying/staging wounds and the importance of reporting such wounds to the provider so an accurate diagnosis can be made. You may want to also offer education to providers about the importance of correct capture of the etiology and clinical criteria to use that diagnosis and why it’s important for the care the patient recieves.

Some organizations require wound care referrals to assess, plan, and monitor treatment for all wounds. This may mean they perform one assessment to ensure proper diagnosis and treatment or they may need to become more involved.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O, CDI education director at HCPro in Middleton, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, click here.