Q&A: Pressure injuries and wound care documentation

Q: According to the Official Guidelines for Coding and Reporting, the stage of a pressure injury can be taken from a nurse's documentation, provided it is also documented by a provider in the same location and with the same etiology. Institutions have the discretion to decide whether or not to accept staging from bedside nurses or wound, ostomy, and continence nurses (WOCN). I am interested in understanding the choices some programs have made in this regard. Specifically, for programs that have chosen not to accept pressure injury staging from nursing staff, including WOCNs, what implications or outcomes have you observed? Additionally, for those that do accept staging from WOCNs, what benefits or challenges have you encountered?

Response #1: Our organization has chosen to only allow WOCN wound staging. We take the staging from WOCNs as long as the provider identifies the diagnosis and related pressure ulcer location in their notes. Providers are often not comfortable staging pressure ulcers.

• Advantages:
  
  • WOCNs have the highest level of expertise and accuracy of assessment
  • This removes the inaccuracies or copy paste documented by the floor nurses
  • CDI specialists may query the provider to add pressure ulcer and location to their notes, as well as present on admission status
• Disadvantages:
  
  • Requires appropriate resources for WOCN coverage so that the assessment and documentation can be conducted in a timely manner

Response #2: Stage 3 or 4 pressure ulcer staging is conducted by wound care nurses. Stages 1 and 2, however, can be taken from any nurse’s documentation. If the physician documents “pressure ulcer stage,” this would trump any nursing documentation.

Of course, there are some challenges with this approach. One challenge is that wound care nurses do not always see every patient with a stage 3 or 4 pressure injury . Although there is a consultation for each patient with a stage 3 or 4 pressure injury, there are not always enough wound care nurses. Nevertheless, documentation from wound care nurses is generally better than the providers or staff nurses.

Response #3: At our institution, a coder does not code from a WOCN’s notes unless the physician has corroborated the WOCN’s notes, as well. The CDI specialists send queries when the physician does not document the accurate wound cause, location, depth, site, stage, and present on admission status. We have an open-ended query for wound care documentation, and we also have a more detailed query for cause, location, depth, etc. This has been very successful. 

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council. For the purposes of this article, all Council member answers have been deidentified.