Ask the Care Expert about ... documentation terms

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Sherrie Dornberger, RN, CDONA, FACDONA, Executive Director, NADONA
Sherrie Dornberger, RN, CDONA, FACDONA, Executive Director, NADONA

At my facility, they are mixing pressure ulcer with other terms. What's correct to use in documenting?

With the updating and changing of the new regulations, many are using a PU/ PI abbreviation. This stands for Pressure Ulcer/ Pressure Injury.

Many times the ulcer is really an injury to the skin. Regulations state that 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.

A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and it may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear.

CMS recognizes numerous terms used to describe alteration in skin integrity due to pressure. Pressure ulcer, pressure injury, pressure sore, decubitus ulcer and bed sore are all used interchangeably.

The other defining factor is avoidable versus unavoidable. “Avoidable” means that the resident developed a pressure ulcer/injury and that the facility did not do the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs and goals, and professional standards of practice; monitor and evaluate the impact of interventions; or revise interventions as appropriate.

“Unavoidable” means that the resident developed a pressure ulcer/injury even though the facility evaluated the resident's clinical condition and risk factors; defined and implemented interventions consistent with resident needs, goals, and professional standards of practice; monitored and evaluated the impact of interventions; and revised the approaches as appropriate.