Jeri Lundgren

Our electronic record system allows only one measurement for a pressure injury. How do I capture a deep tissue injury that has an open area within it?

Medical records should always capture the full extent of a pressure injury. Since your electronic health record system only allows one measurement, you should input the measurement of the entire deep tissue injury (DTI), rather than only the portion that is open.  

It is important to understand how pressure injuries form. Most pressure injuries start at the bone muscle interface. Muscle tissue is much more sensitive to the effects of pressure than skin. In a sense, a pressure injury is much like an iceberg. By the time you see an indication that there might be tissue damage at the skin level, there is much more damage underneath. Most DTIs present as intact skin that is dark maroon or purple in discoloration. Then the skin will superficially erode within the DTI. The DTI may go on to form eschar and/or slough within as it continues to expose the true extent of tissue damage. 

Discolored skin, regardless of whether it is intact or open, is a part of the wound. If you input only the measurement of the open area within, over time it could seem as if the wound were getting larger and declining. In fact, what is emerging is just the expected erosion of the DTI. Instead, measure the entire DTI by including the intact, discolored skin, and then measure the open area within. In your electronic health record, input the entire DTI measurement, and in the progress notes, document the measurement of the open area eroding within.  

When describing the wound base, describe the entire DTI. Therefore, your documentation might state, “The sacrum DTI has intact skin with dark purple discoloration, with an open area within that is 80% slough and 20% granulation.” This accurately reflects the entire area affected.