Incorrect staging of pressure injuries can cause many types of repercussions. Incorrect documentation can also be worse than no documentation. Pressure injuries and staging mistakes are avoidable, so educating clinicians how to stage with confidence is the goal.

Proper Documentation of Pressure Injuries: What You Can Do

When I teach the pressure injury staging system, I not only focus on the layers of the skin structure, but also on location, shape, and color. I encourage the clinician to sort of paint a picture of the wound, and tell the story in their documentation. This way, you are truly understanding the level of tissue destruction, as well as validating the stage of pressure injury.

If I were to have a small group of physicians and clinicians assess five different pressure injuries, it would result in and array of different measurements—some with a depth measurement (or not), different tissue percentages, and varying stages. Ongoing education and mentoring will close the gap with wound assessment inconsistencies.

It Only Takes One Word to Incorrectly Stage a Pressure Injury

I see a wide variety of inconsistencies in wound documentation when reviewing legal cases and auditing provider/nursing documentation for State Survey readiness in nursing homes. As a wound expert, I know what I am looking for as I comb through medical records. I know that it only takes only ONE word to make a case.

Here are a few scenarios to think about:

Scenario #1: You have a patient with a non-blanchable area to the left heel. You describe the injury as an erythematous, pink, and dry area with a measurement of 4x4x0.1cm. The wound has been staged as a Pressure Injury Stage 1.

INCORRECT: The measurable depth warrants tissue loss, along with pink wound tissue, which validates a Stage 2 Pressure Injury = partial-thickness.

Scenario #2: You have a patient with pressure injury to the coccygeal region. You document that the wound is 100% pink granulation. You stage the wound as a Stage 2 Pressure Injury.

INCORRECT: Granulation is not possible in a Stage 2 Pressure Injury. Referring to the wound bed tissue as granulation validates a full-thickness wound. The wound is a Stage 3 Pressure Injury = full-thickness.

Scenario #3: You have a patient admitted to your facility with a pressure injury to their right heel. It presents 80% black eschar and 20% yellow slough. You palpate the area and feel comfortable documenting a Stage 3 Pressure Injury. The following week during rounds, you notice a small pinpoint area within the eschar, and slough mix you can now probe to bone. The stage is now a 4, showing a decline in wound progress.

INCORRECT: The devitalized tissue percentage validates an Unstageable Pressure Injury. Staging the pressure injury a 3 on admission made it appear the wound had declined. Is it also possible the pinpoint open area was missed on admission? The tissue level of destruction was full thickness on admission, and possibly to bone.

Scenario #4: Moisture-associated skin damage is being measured 3x3x0.2cm. The tissue is 20% slough and 80% granulation.

INCORRECT: This area is now full-thickness. Any devitalized tissue validates full-thickness tissue level of destruction. The wound must now be staged. It would be a Stage 3 Pressure Injury.

Helpful Resources for Learning Pressure Injury Staging

1. NPUAP Pressure Injury Stages: http://www.npuap.org/resources/educational-and-clinical-resources/npuap…
2. Pressure Injury Staging Illustrations: http://www.npuap.org/resources/educational-and-clinical-resources/press…
3. NPUAP Image Library: http://www.npuap.org/resources/educational-and-clinical-resources/image…

About the Author
Cheryl Carver is an independent wound educator and consultant. Carver's experience includes over a decade of hospital wound care and hyperbaric medicine. Carver single-handedly developed a comprehensive educational training manual for onboarding physicians and is the star of disease-specific educational video sessions accessible to employee providers and colleagues. Carver educates onboarding providers, in addition to bedside nurses in the numerous nursing homes across the country. Carver serves as a wound care certification committee member for the National Alliance of Wound Care and Ostomy, and is a board member of the Undersea Hyperbaric Medical Society Mid-West Chapter. She is the first LPN to be inducted as an Association for the Advancement of Wound Care (AAWC) speaker.