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Features: Clinical Perspectives

Documentation with MDS Section M: Skin Condition

Zulkowski, Karen M. DNS, RN, CWS; Tellez, Robin MS/HSA, RN, CWS; van Rijswijk, Lia BSN, RN, CWCN, COCN

Author Information


In 1987, the United States Congress mandated the use of a uniform assessment instrument for federally funded long-term-care facilities through the passage of the Omnibus Budget Reconciliation Act.1 Shortly thereafter, the Resident Assessment Instrument (RAI) was designed to be the comprehensive assessment and care planning tool used in all federally funded long-term-care facilities.

There are 2 components of the RAI: the Minimum Data Set (MDS) and the Resident Assessment Protocols (RAPs). The MDS is the assessment component of the RAI. The RAPs identify 18 clinical areas through specific items in the MDS that require facility staff to initiate a plan of care.

Because the MDS is used by long-term-care facilities to obtain reimbursement from Medicare and Medicaid, accurate assessment and documentation on the MDS form is imperative to the financial health of an institution. Long-term-care facility deficiency citations and quality indicators are derived from the MDS. Deficiency citations are available to the public via the Internet; quality indicators will soon be available as well. Because this information is accessible to the public, the MDS may influence public perception of the adequacy of care delivered in a long-term-care facility.

It is crucial for a long-term-care facility to capture accurate information on the MDS form. However, the Health Care Financing Administration (HCFA) has made no provisions or mandate for inter-rater reliability training for practitioners who perform the MDS assessment. In addition, the practitioner responsible for performing the MDS assessment varies widely among facilities. Some facilities designate 1 person to do all of the assessments. The original intent, however, was to have all levels of staff from all shifts providing input on the MDS form. The MDS was designed to tie the provision of care to daily documentation in the areas that are listed on the form.

The MDS form was designed to capture the minimum amount of information needed for a resident's assessment and subsequent plan of care. Documentation in a resident's medical record should complement the MDS assessment. The MDS assessment should also prompt essential documentation necessary to support clinical decision making. For some sections of the MDS, this is straightforward. In Section I: Disease Diagnosis, for example, if a medical condition is documented in a resident's medical record, it is checked on the MDS form. In Section M: Skin Condition, this is not the case. Clinical practice guide-lines, which are used for day-to-day decision making, do not match the MDS assessment.

For example, the Agency for Health Care Policy and Research (AHCPR; now the Agency for Healthcare Research and Quality) and the National Pressure Ulcer Advisory Panel (NPUAP) provide clinical practice guidelines for pressure ulcer (PU) care.2-4 Neither guideline, however, is designed to direct documentation and assessment of leg or foot ulcers. In the AHCPR guideline, there is no staging system for venous ulcers, and the staging system for diabetic foot ulcers is different from the NPUAP PU staging system.2,3 The NPUAP staging system was not designed to assess PUs over time and its validity and reliability have not been established.4 To further complicate matters, the AHCPR and NPUAP guidelines for wound assessment differ from what is described in the MDS, as will be illustrated in this article.

The problem for facilities and their staff is that clinical practice guidelines and MDS assessments have been the basis of malpractice lawsuits when care was not documented properly. In fact, more than $11 million in plaintiff compensation could have been avoided in a single year if clinical practice guidelines had been followed and properly documented in medical records.5-7

In this article, examples of medical record documentation necessary to support the MDS assessment will be provided. Each question contained in Section M: Skin Condition (Figure 1) will be compared with clinical practice guidelines and/or MDS-specified definitions, and the necessary documentation will be described for each question.

Figure 1
Figure 1:


Question 1: Ulcers (Due to any cause)

This question prompts the practitioner to record the number of ulcers at each stage, independent of their cause. The definitions of an ulcer from the MDS, NPUAP, and AHCPR are listed in Table 1. For the MDS, HCFA requires all ulcers to be staged-not just PUs-and to be reverse staged as they heal. This contradicts the recommendations of the AHCPR clinical practice guideline and the NPUAP, which oppose reverse staging of PUs.8 In addition, the MDS classifies an ulcer as Stage IV if eschar is present, and the AHCPR states that an ulcer with eschar is unstageable.2,3

Table 1
Table 1:

Question 2: Type of ulcer

Question 2 requires the practitioner to record the highest stage pressure or stasis ulcer presenting in the last 7 days. Because this question lists only 2 types of ulcers-stasis and pressure-it is possible to have multiple ulcer sites that are not recorded on the MDS form. The ulcers not recorded on the form, however, must be documented in the resident's medical record and a subsequent treatment plan developed. Arterial, venous, and diabetic ulcers are not specified in the MDS. Table 2 lists the definitions of ulcer types from the MDS and compares them with definitions found in recent literature.

Table 2
Table 2:

Documentation needed to support questions 1 and 2

Because optimal clinical practice differs from the basic assessment information contained in the MDS, proper documentation on a resident's medical record is imperative. Health care practitioners who document the stage of a PU should have a basic understanding of the anatomy and physiology of the skin and wound healing. The description of a wound must include its location, size, and a description of the wound bed, edges, and surrounding skin. This assessment must also be completed and included in all follow-up documentation. For example, if a wound is assessed as a Stage IV PU on the admission MDS form and shows some improvement by the MDS quarterly assessment, the wound will be documented as a Stage II or III PU on the quarterly MDS form. This type of reverse staging, however, should not be recorded in the medical record.8 The medical record must contain an accurate description of the wound, including its size, and a description of the wound bed, edges, and surrounding skin (Figure 2).

Figure 2
Figure 2:

Because wound causation and depth affect healing time, wounds are often classified as surgical or nonsurgical, acute or chronic, and by depth-superficial, partial-thickness, or full-thickness. The terms for wound classification by depth are defined in Table 3. These terms can be used for wound description in the medical record and are part of the qualifying parameters for ulcer staging.9 None of these terms are defined in the MDS.

Table 3
Table 3:

The presence of necrotic tissue must also be documented in the medical record. On the MDS form, a wound with necrotic tissue is classified as a Stage IV PU; however, it is impossible to accurately stage an ulcer until the necrotic tissue has been removed or debrided. Necrotic tissue can delay wound healing and may increase the risk of infection. If necrotic tissue is found, the resident's physician must be notified and a plan of treatment initiated.10,11

Question 3: History of resolved ulcers

This is a straightforward yes or no question: Has the patient had a resolved (healed) ulcer within the last 90 days? It is important to note that recently wounded skin regains only up to 80% of its previous tensile strength. If a resident previously had a PU, he or she will be at a higher risk for another PU.11

Documentation needed to support question 3

If a resident previously had an ulcer, it is important to document the location of the ulcer, how long ago it resolved, and the ulcer type and stage, if known. The resident's medical record may need to be consulted to make this determination on admission. Relying only on medical records, however, may result in missing prior ulcers. Studies at acute care hospitals have shown that documentation was not present in 19% to 35% of the patients admitted with PUs.12,13 A careful skin care assessment conducted on admission will reveal the presence of scarring, which should be noted in the medical record and followed up with the resident or the resident's family.

Question 4: Other skin problems or lesions present

The purpose of this question is to document the presence of skin problems-other than ulcers-and conditions that indicate risk factors for more serious problems. Table 4 lists the MDS definitions of "other skin problems." It is important for staff to consider the presence of other skin problems or lesions when planning a PU risk prevention program. In 1 study, the presence of other skin problems or lesions was found to be correlated with the prevalence of PUs in newly institutionalized elderly.14

Table 4
Table 4:

Documentation needed to support question 4

Tape burns, excoriation due to urinary or fecal incontinence, and surgical sites that include partial- or full-thickness tissue loss should not be staged as ulcers in the resident's MDS assessment. These should be documented in the resident's medical record in more detail.11

The practitioner should assess a resident for skin that is desensitized to pain or pressure. A resident at risk for desensitization may be comatose or have hemiplegia/hemiparesis, quadriplegia, paraplegia, peripheral vascular disease, or neurologic disorders. There may be documentation of this in the resident's previous medical record or it may need to be assessed by the practitioner. The RAI manual provides a detailed procedure for the assessment of skin sensation using a disposable safety pin or "orange stick" (see Test for Skin Sensation).15

Question 5: Skin treatments

This question prompts the practitioner to list the specific treatments for a resident's skin conditions. "Skin treatment" definitions from the RAI manual are listed in Table 5. The answer to this question should include the use of preventive devices, interventions, and treatments for the skin disorders identified in questions 1 through 4. Conditions or problems of the feet are not coded here; they are addressed in question 6.

Table 5
Table 5:

Documentation needed for question 5

A resident's care plan should expand on the MDS assessment and include specific devices and interventions employed for the prevention and treatment of a resident's skin conditions. Some examples of interventions that should be documented are:

Nutrition and hydration. Nutritional intervention is frequently underreported for PU treatment and prevention. One study conducted in the acute care setting showed that nutritional supplements were ordered for only 19% of newly admitted elderly patients, despite the fact that 65% were assessed by the nursing staff as having nutritional problems.13 Another study conducted in the long-term-care setting showed that dietitians ordered nutritional supplements for 94% of the residents.16 In this study, nurses documented nutritional support on the MDS as being necessary for only 5% of the residents with PUs, despite the fact that 82% of the residents had below-normal serum albumin levels.

Wound care. Documentation should specify the type of dressings and products used for ulcer treatment or surgical wound care.

Moisture barriers and hydrating lotions. The use of preventive measures, such as moisture barriers or hydrating lotions, should be specified in the medical record. Synthetic sheepskin is not recommended as a moisture barrier. Natural sheepskin is preferable because it provides natural lanolin to exposed skin,17 although it is expensive and is not washable.

Support surfaces. The use of bed or seat cushions should be documented in the medical record and the products should match the resident's activity capabilities.

Turning/repositioning program. A resident's turning/repositioning program should be documented in the medical record. It is important to note that the traditional 2-hour turning schedule may not be appropriate for some residents. Patients may need to be turned as frequently as 1 to 1 1/2 hours or as infrequently as once every 3 to 4 hours, if frequent turning is contraindicated.2,3

Question 6: Foot problems and care

The final question of Section M of the MDS is designed to document all disorders of the foot, including nondraining skin lesions (corns, calluses), open lesions of all etiologies (arterial and diabetic), structural deformities (hammer toes and bunions), and treatments for preventive and palliative care. Table 6 lists the RAI definitions of foot problems and treatments. This question allows ulcers not covered in question 2 to be recorded in the MDS.

Table 6
Table 6:

Documentation needed for question 6

Ulcers or open lesions of the foot-such as diabetic or arterial ulcers-should be included in the answer to this question. If an ulcer is present, documentation should follow the same parameters as ulcers documented in questions 1 and 2. In addition, nail care (such as trimming), podiatry consultation, wound debridement, specific dressings, and treatments should be documented in a resident's medical record to support the MDS assessment.


Completing the MDS, developing a comprehensive care plan, tying care planning to day-to-day activities, and documenting findings and interventions in the medical record are complicated tasks. Establishment of competency in MDS assessment is not mandated by HCFA, although several organizations are available to help. The American Association of Nurse Assessment Coordinators (AANAC) is working to establish a certification program for MDS coordinators to help standardize the assessment and coding process in long-term-care facilities. The American Academy of Wound Management (AAWM) has established a certification program for health care professionals who work with wounds and skin disruptions of all etiologies.

The MDS captures the minimum amount of information about a patient and it is inconsistent with current guidelines of assessment. Section M: Skin Conditions is one of the most challenging sections of the MDS to complete. Health care practitioners need a basic understanding of PU risk prevention and treatment to provide a comprehensive, well-documented picture of a resident. Correct descriptive terminology must be used in documentation to ensure a comprehensive record and to protect the facility and staff from expensive litigation.

Congruency among the MDS assessment, care planning, current practice guidelines, and research is needed. This would result in better patient care and improved reimbursement for the care provided to each resident.


1. Brandeis GH, Berlowitz DR, Hossain M, Morris JN. Pressure ulcers: the Minimum Data Set and the Resident Assessment Protocol. Adv Wound Care 1995;8(6):18-25.
2. Panel on the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline, No. 3. AHCPR Publication No. 92-0047. Rockville, MD: Agency for Healthcare Policy and Research; May 1992.
3. Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of Pressure Ulcers. Clinical Practice Guideline, No. 15, AHCPR Publication No. 95-0652. Rockville, MD: Agency for Health Care Policy and Research; December 1994.
4. National Pressure Ulcer Advisory Panel. Pressure Ulcers: Incidence, Economics, Risk Assessment. Consensus Development Conference Statement. West Dundee, IL: S-N Publications; 1989, p 3-4.
5. Goebel RH, Goebel MR. Clinical practice guidelines for pressure ulcer prevention can prevent malpractice lawsuits in older patients. J Wound Ostomy Continence Nurs 1999;26:175-84.
6. Bennett RG, O'Sullivan J, DeVito EM, Remsburg R. The increasing medical malpractice risk related to pressure ulcers in the United States. J Am Geriatr Soc 2000;48:73-81.
7. Soloway DN. Civil claims relating to pressure ulcers: a claimants' lawyer's perspective. Ostomy Wound Manage 1998;44 (2):20-4, 26.
8. National Pressure Ulcer Advisory Panel. NPUAP Statement on Reverse Staging of Pressure Ulcers. NPUAP Report, Vol 4, No 2. Reston, VA: NPUAP; September 1995.
9. van Rijswijk L. Clinical practice guidelines: moving into the 21st century. Ostomy Wound Manage 1999;45(suppl):47S-53S.
10. van Rijswijk L. Wound assessment and documentation. In: Krasner D, Kane D, editors. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 2nd ed. Wayne, PA: Health Management Publications, Inc; 1997.
11. Zulkowski K, Tellez R, van Rijswijk L. Accurately Assessing Skin Conditions. Denver, CO: American Association of Nurse Assessment Coordinators; 2000.
12. O'Brien SP, Wind S, van Rijswijk L, Kerstein M. Sequential biannual prevalence studies of pressure ulcers at Allegheny-Hahnemann University Hospital. Ostomy Wound Manage 1998;44(3A Suppl):78S-89S.
13. Zulkowski K. Examination of care planning needs for elderly newly admitted to an acute care setting. Ostomy Wound Manage 2000;46(1):32-8.
14. Zulkowski K. MDS+ RAP items associated with pressure ulcer prevalence in newly institutionalized elderly. Ostomy Wound Manage 1998;44(11):40-53.
15. Morris J, Murphy J, Nonemaker S, et al. Minimum Data Set 2.0. Long Term Facility Resident Assessment Instrument User's Manual. Des Moines, IA: Briggs Healthcare Products; 1995.
16. Zulkowski K. A conceptual model of pressure ulcer prevalence: MDS+ items and nutrition. Ostomy Wound Manage 1999;45(2):36-44.
17. Marchand AC, Lidowski H. Reassessment of the use of genuine sheepskin for pressure ulcer prevention and treatment. Decubitus 1993;6(1):44-7.
18. Kerstein MD. The non-healing leg ulcer: peripheral vascular disease, chronic venous insufficiency, and ischemic vasculitis. Ostomy Wound Manage 1996;42(10A Suppl):19S-35S.
    19. Armstrong DG, Lavery LA, Wunderlich RP. Risk for diabetic foot ulceration: a logical approach to treatment. J Wound Ostomy Continence Nurs 1998;25:123-8.

    Test for Skin Sensation

    To test for skin desensitization, use a new disposable safety pin or "orange stick" typically used for nail care.

    Ask the resident to close his or her eyes. If the resident cannot keep his or her eyes closed or cannot follow directions, block the resident's view of the limb being tested with a cupped hand or towel.

    Lightly press the pointed end of the pin or stick against the resident's skin. Do not press hard enough to cause pain, injury, or break the skin. Use the pointed and blunt ends of the pin or stick alternately to test sensations on the resident's arms, trunk, and legs. Ask the resident to report if the sensation is "sharp" or "dull."

    Compare the sensations in symmetrical areas on both sides of the body.

    If the resident is unable to feel the sensation or cannot differentiate sharp from dull, the area is considered desensitized to pain sensation.

    For residents who are unable to make themselves understood or who have difficulty understanding directions, rely on facial expressions (eg, flinching, grimacing, or surprise), body motions (eg, pulling the limb away), or sounds to determine if they can feel the instrument.

    Do not use pins with agitated or restless residents. Abrupt movements can cause injury.

    Always dispose of the pin or stick after each use to prevent contamination.

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