Q&A: Pressure injury staging 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 to accept staging from bedside nurses or wound, ostomy, and continence nurses (WOCN). 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 staging of wounds by our wound care nurses. We take the staging from our 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. Here is the pro/con breakdown of WOCNs and staging documentation at our institution:

• Advantages:
  
  • WOCNs have the highest level of expertise and accuracy of assessment
  • This removes the inaccuracies or copy paste documented by the floor nurses
  • A CDI specialist may query provider to add pressure ulcers and location to their notes, as well as present on admission status
• Disadvantages:
  
  • Requires the appropriate level of resources to ensure WOCNs can complete the documentation in a timely manner

Response #2: At our institution, stage three or four pressure injury documentation is done by WOCNs. Stages one and two pressure injury documentation, on the other hand, can be taken from any nurse. If the physician documents a pressure injury stage, however, it will trump any nursing documentation.

Of course there are some challenges with this approach. One is that WOCNs do not always see every patient with a stage three or four pressure injury. Although there is a consultation for each patient with a stage three or four pressure injury, there are not always enough WOCNs. The documentation from the WOCNs is generally better than the providers or staff nurses. Additionally, since there are fewer WOCNs when we have a concern or question related to documentation, it is an easier group to reach.

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.