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Pressure ulcers: The stakes just got higher

Meehan, Marge RN, MIM, WCC

doi: 10.1097/01.NURSE.0000361266.14966.7f

To improve patient safety and ensure reimbursement, make sure you understand the new nursing assessment and documentation standards detailed here.

Marge Meehan is an independent wound consultant in Clarksville, Md.

How do you assess and document these wounds according to new reimbursement rules?



PRESSURE ULCERS are a persistent problem. Federal guidelines for preventing and treating them have been available for over 10 years, but their prevalence across all healthcare settings has remained generally constant.1 Also, pressure ulcers are costly, both in terms of patient suffering and use of healthcare resources.

Beginning last fall, the stakes in preventing pressure ulcers got even higher: Under new reimbursement rules from the Centers for Medicare and Medicaid Services (CMS), a patient's pressure ulcer must be identified and documented within 2 days of admission in order for the facility to be reimbursed for the cost of treating the ulcer. The purpose is to encourage facilities to recognize risks early and take steps to avoid hospital-acquired pressure ulcers, which are generally considered to be avoidable complications. However, CMS acknowledges that some pressure ulcers are unavoidable, and even healthcare providers are divided on whether pressure ulcers can always be prevented.1

This article explains how to document pressure ulcer risk assessment and findings, and provides steps you should take to improve patient care and prevent avoidable skin breakdown.

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Documentation challenges

Suppose you find a pressure ulcer while performing a thorough skin and risk factor assessment on a patient at admission. Documenting it according to CMS regulations is crucial for your facility to get CMS reimbursement. Your assessment findings and documentation establish the true condition of the patient's skin at the time of admission. (Be sure to use an appropriate, valid, and reliable scale such as the Braden Scale to perform a pressure ulcer risk assessment.2)

Under CMS regulations, the status of your patient's pressure ulcer must be documented as part of the admission assessment process. The documentation must be done by a physician or other person legally responsible for establishing patient diagnosis. Your patient's admission documentation will be used to determine if a pressure ulcer was:

  • present at time of inpatient admission
  • not present at admission
  • unknown because documentation was insufficient
  • clinically undetermined, meaning the healthcare provider couldn't clinically determine whether a pressure ulcer was present.3

Your documentation should help you identify the cause of skin breakdown. Avoid the temptation to call any skin breakdown a pressure ulcer. Remember that pressure ulcers are caused by pressure (alone or in combination with shear or friction) and generally occur over bony prominences on the body.4 These forces can be controlled with interventions such as therapeutic mattresses, pull-sheets, and barrier creams (to protect the skin from moisture, a contributing factor). Ulcers that develop because of the patient's chronic circulatory problems or poorly controlled diabetes may not be pressure ulcers.

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Meeting the challenges

To ensure proper documentation of the patient's skin condition at admission, make sure that the physician or person responsible for making patient diagnoses has all the relevant patient data, such as patient risk factors for pressure ulcers (history of previous ulcers or comorbidities such as peripheral vascular disease or diabetes). If the patient has an ulcer, provide a comprehensive description that includes ulcer dimensions, location, and characteristics. When assessing your patient's skin, remember that:

  • Darker skin tones can be harder to assess, so make sure you have adequate light when you examine the skin. Also remember that darkly pigmented skin may not blanch visibly under pressure. Instead of blanching, look for color differences compared with surrounding skin.4
  • Skin damage can start below the skin surface, so include tactile assessment of the patient's skin. Skin temperature warmer or cooler than surrounding skin, presence of induration, or discoloration of the skin relative to surrounding areas may provide the only clues to deep tissue injury.4 A pressure ulcer that results from deep tissue injury appears suddenly, but once opened, can extend deep into soft tissue, including the fat layer or muscle, and even bone.
  • Previously damaged intact skin can be very fragile. Ask about previous skin breakdown that has healed, or a history of radiation therapy that may have made exposed areas of skin extremely fragile. Consider risk factors for other types of skin breakdown beyond those captured by your pressure ulcer risk assessment tool, such as contractures, poor circulation, and diabetic neuropathy.
  • Document pressure ulcers by stage and location. Use the National Pressure Ulcer Advisory Panel's (NPUAP's) staging system to describe pressure ulcers.4 Measure and document the ulcer dimensions, and document ulcer characteristics (such as presence or absence of exudate, presence of odor, and induration), and the ulcer's anatomic location.

The second challenge is to correctly identify the cause of skin breakdown. Work closely with the other members of the healthcare team. Remember, you're far more likely to be focused on the patient's skin condition than the healthcare provider, who's concentrating on the primary reason for the patient's admission. Your assessment provides important details about skin condition and risk factors for various types of skin breakdown, including pressure ulcers, vascular ulcers, and diabetic ulcers. Skin breakdown caused by factors other than pressure, shear, friction, and moisture is more likely to be recognized if your documentation reflects those risk factors. The key is to assess and document all risk factors, what you're doing to control them, and how and when you made adjustments to the nursing care plan.

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Daily diligence

Document and repeat pressure ulcer risk assessment and skin assessment daily. Critically ill patients or those with significant changes in their clinical condition may need more frequent assessment.5 Record details that will help you identify trends and determine if the pressure ulcer or skin breakdown has improved or worsened. Take measurements, including ulcer depth, and document the condition of the wound bed and the condition of the periwound skin. This kind of trend or progress report helps you decide if you need to change your interventions, or if you need to reconsider the probable cause of the ulcer or skin breakdown. If your facility documents all types of wounds on a single form, make sure the form lets you distinguish between pressure ulcers and other types of ulcers.

Use the right classification system based on the type of ulcer. For example:

  • NPUAP's staging system is designed for pressure ulcers and focuses on the depth of the wound.
  • The University of Texas Diabetic Foot Wound Classification System is designed for diabetic (also called neuropathic) ulcers, and measures contributing factors such as infection and ischemia.6
  • The CEAP classification system—Clinical severity, Etiology, Anatomic, and Pathophysiological—is designed for venous ulcers.7

Each system is designed to capture information important for determining the ulcer's severity and status.

If you don't know or aren't sure of the ulcer's etiology, thoroughly describe the ulcer's characteristics. Here's what to include:

  • wound depth—for example, whether the wound is full-thickness, penetrating through the dermal layer of skin, or partial-thickness, affecting only the dermal layer. Stage III and IV pressure ulcers have full-thickness tissue losses, but remember that the measured depth of these ulcers varies depending on their anatomical location. In places with little subcutaneous tissue, such as the occiput and malleolus, these ulcers can be shallow.4
  • signs and symptoms of infection, such as erythema, pain, edema, exudate, and warmth.
  • the shape and location of the wound, which can provide hints about the physical forces at play. For example shearing forces, usually caused by dragging a patient across the surface of the bed, result in ragged damage to skin and undermined areas of tissue damage. Irregularly shaped ulcers on the gaiter area of the leg (the area from the malleolus to mid-calf) may be caused by vascular insufficiency. Ulcers with well-defined borders that are found between the toes or on weight-bearing areas of a cool leg are more likely to be arterial than pressure ulcers.

The care plan should reflect the patient's goals and priorities. The patient has the right to refuse any intervention, regardless of the likely consequence of that choice. Be sure to record the patient's preferences and key points of your teaching efforts in explaining the purpose and goals of the intervention being refused.

Choose prevention interventions based on specific patient factors. For example, foam wedges may be necessary to maintain lateral position changes for cognitively impaired patients. Whatever interventions you use, be sure to document why and when you use them.

Pressure ulcers, cloaked in their unfortunate connotations of neglect or safety error, can complicate goal setting. Use interventions that address the consequences of pressure, shear, friction, and excessive moisture. Many wound-care products are available to help you individualize treatment. Remember, what works for one patient may not work for another, even if their wounds are similar.

By recognizing, describing, documenting, and communicating the skin condition of every patient who enters your hospital, you may be able to improve diagnosis and prevent avoidable complications.

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1. National Pressure Ulcer Advisory Panel Board of Directors. Pressure ulcers in America: prevalence, incidence, and implications for the future. An executive summary of the National Pressure Ulcer Advisory Panel monograph. Adv Skin Wound Care. 2001;14(4)(Part 1):208–215.
2. Braden Scale for Predicting Pressure Sore Risk..
3. Present on Admission Indicator. CMS Manual System. Pub 100-04 Medicare Claims Processing. Transmittal 1240. May 11, 2007..
4. National Pressure Ulcer Advisory Panel. Pressure Ulcer Definition and Stages. February 2007..
5. Institute for Healthcare Improvement. 5 Million Lives Campaign. Prevent pressure ulcers..
6. Sussman C, Bates-Jensen BM. Wound Care: A Collaborative Manual for Health Professionals. Lippincott Williams & Wilkins; 2006.
7. Eklof B, Rutherford RB, Bergan JJ, et al. American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40(6):1248–1252.
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Brandeis GH, Berlowitz DR, Katz P. Are pressure ulcers preventable? A survey of experts. Adv Skin Wound Care. 2001;14(5):244–248.
Sharp C, McLaws ML. Estimating the risk of pressure ulcer development: is it truly evidence based? Int Wound J. 2006;3(4):344–353.
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    © 2009 Lippincott Williams & Wilkins, Inc.