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| *to see a priority list of the most SIGNIFICANT COMPLICATIONS that we are collecting for Medicine patient go to: [[Significant complications medicine]].
| | {{PreICD10 dx |
| | | NewDxArticle = Decubitus (pressure) ulcer, stage not indicated}} |
| | {{PreICD10 dx |
| | | NewDxArticle = Decubitus (pressure) ulcer, Stage I (surface reddening) |
| | }} {{PreICD10 dx |
| | | NewDxArticle = Decubitus (pressure) ulcer, Stage II (to fascia, just under skin) |
| | }} {{PreICD10 dx |
| | | NewDxArticle = Decubitus (pressure) ulcer, Stage III (deep, to but not including muscle) |
| | }} {{PreICD10 dx |
| | | NewDxArticle = Decubitus (pressure) ulcer, Stage IV (involves muscle, tendon, or bone) |
| | }} |
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| {{DX tag | Dermatological Non-Infectious | | Ulcers - Decubitus only | ULCERS - DECUBITUS only |
| | [https://en.wikipedia.org/wiki/Pressure_ulcer for more info see: Wikipedia] |
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| *[[94500 - Ulcers - Decubitus only]] | | {{DX tag | Dermatological Non-Infectious | Medical Problem | Ulcers - Decubitus only | ULCERS - DECUBITUS only | |
| | *94500 - Ulcers - Decubitus only (''generic'') |
| *94501 - Stage 1 - surface reddening of skin | | *94501 - Stage 1 - surface reddening of skin |
| *94502 - Stage 2 - just under skin | | *94502 - Stage 2 - just under skin |
| *94503 - Stage 3 - deep-to muscle | | *94503 - Stage 3 - deep-to muscle |
| *94504 - Stage 4 - full layer-to bone| No | 0 | | | | '''}} | | *94504 - Stage 4 - full layer-to bone |
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| | *94505 - Unstageable - can't see wound bed |
| == Collectability of Decubitus Ulcers==
| | | No | 0 | | | 2004 | }} |
| {{Discussion}}
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| Are collectors able to easily pick up from charts if patient has a decubitus ulcer? Reason I am asking is that one site is reporting a high number of bedsores compared to others? Wondering if there collection practice differences?--[[User:TOstryzniuk|TOstryzniuk]] 15:00, 30 April 2010 (CDT)
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| === HSC === | | == When to use the generic dx == |
| *HSC B3- Pat is finding that there is poor documentation on charts about when and decubitus ulcer present on admission or when acquired after coming to a ward. (exception, HSC_D5 is excellent with documentation. Stage of ulcer is rarely documented in the chart. Pat looks at the nursing FLOW SHEET for indication of some sort of a dressing change that would clue her in that there may be a bed sore. Pat will then track down a bedside nurse to find out what dressing is for and if bedsore what would be the stage. Most time it is a guess because of poor documentation by both Doc and Nurse.[[User: PStein | PStein]]
| | Use the generic entry when one of the following is true: |
| | * the wound was not assessed |
| | * there was insufficient info in the chart to determine stage |
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| *On A4 I check for the following:note from Dr Embil (if applicable),nurse's notes, any consults if they mention it/them, nursing flow sheet. Quite often it is a guessing game for the most part.--[[User:CMarks|CMarks]] 11:37, 6 May 2010 (CDT)
| | == When to use the Unstageable dx == |
| ** Con, what does Dr. Embil say about Decubitus Ulcers? He is infection control, right? [[User:Ttenbergen|Ttenbergen]] 11:41, 6 May 2010 (CDT)
| | Wound bed can't be seen so true stage can't be determined. |
| ***He usually handles DFU but will mention decubitus ulcers if they are infected and there is difficulty treating them with an appropriate antibiotic or if one is not required at all.--[[User:CMarks|CMarks]] 11:48, 6 May 2010 (CDT)
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| **** So Dr. Embil's notes would not include Stage1s then, usually, right? [[User:Ttenbergen|Ttenbergen]] 11:55, 6 May 2010 (CDT)
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| === STB === | | ==Start Dates== |
| * For critical care we can only put in 9 complications and bedsores is just not a top priority. If this is important to capture then we would need to add it to our tmp file. If the nurses don't chart skin breakdown there is no way to tell if it was there. We can only use what is written down as sometimes we are looking at charts after the patient is discharged. Documentation can be poor for this sometimes, I agree. --[[User:LKolesar|LKolesar]] 12:55, 3 May 2010 (CDT) | | *2017-Aug-24: unstageable |
| | | *2004-Jun: Med |
| === VIC ===
| | *2004-Jan: ICU |
| *At the Vic we have skin and wound asessment/intervention sheets that we check to see if pts have any problems also we check Patient care flow sheet to see if anything has been documented and also as above if we use up 9 complications this problem gets omitted also lack of nursing staff on the wards equals lack of documentation | |
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| === GRA ===
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| * The Medicine flow sheets at the Grace have a large area for daily documentation of skin care and integrity; usually reddened areas and wounds are noted here. To accurately grade the ulcer we use Braden score sheets which are filled in fairly well, otherwise the documentation is found on the IPN. | |
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| === CON ===
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| We have a section in our flow sheet for skin integrity. If the wound is such that they have consulted the wound care nurse, then I will have a good idea of how deep it is, but otherwise not. Generally if the wound is infected I will be able to pick that up in the charting too. Often I will see a new dressing, but am not able to find out why the drsg is being applied.
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| === OAK ===
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| ???
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