Ulcers - Decubitus only: Difference between revisions

From CCMDB Wiki
Jump to navigation Jump to search
m (m)
m (Text replacement - "Decubitus (pressure) ulcer, Stage IV (involves bone)" to "Decubitus (pressure) ulcer, Stage IV (involves muscle, tendon, or bone)")
 
(25 intermediate revisions by 8 users not shown)
Line 1: Line 1:
{{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)
}}
[https://en.wikipedia.org/wiki/Pressure_ulcer  for more info see: Wikipedia]
{{DX tag | Dermatological Non-Infectious | Medical Problem | Ulcers - Decubitus only | ULCERS - DECUBITUS only |
{{DX tag | Dermatological Non-Infectious | Medical Problem | Ulcers - Decubitus only | ULCERS - DECUBITUS only |
*[[94500 -  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
*94505 Unstageable - can't see wound bed
== Collectability of Decubitus Ulcers==
| No | 0 |  |  | 2004 | }}
{{Discussion}}
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)[[User:TOstryzniuk|Trish Ostryzniuk]] 22:24, 2012 October 12 (CDT)
 
*'''is the Braden Bed score sheet being used on all medicine wards now in the Region'''?[[User:TOstryzniuk|Trish Ostryzniuk]] 19:07, 2012 October 11 (CDT)
**Yes all Hsc medicine wards use the Braden Score.--[[User:CMarks|CMarks]] 13:33, 2012 November 16 (EST)
***yes all GGH medicine wards use the Braden Score [[User:Lkaita|Lisa Kaita]] 12:26, 2017 May 18 (CDT)
 
=== HSC ===
====ICU HSC====
*?
 
====Medicine HSC====
*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]]
 
*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)
 
=== STB ===
====ICU STB====
*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)
**what we are seeing in ICU 2010-2012 is that Decubitus is not coded in admit or acquired. In these 153 cases where TISS76 item84is marked but not coded in diagnosis, 60 have all 6 admit slots filled up but only 3 have all 9 complication slots filled up. So the reason reason being that complication slots are mostly filled up is not a correct assumption.  One of the issue at STB is that collectors don't find clear documentation in chart.[[User:TOstryzniuk|Trish Ostryzniuk]] 19:03, 2012 October 11 (CDT)
***It is important to note that if skin breakdown is already present on admission, it will not be put in the complication section even if there is room for this. --[[User:LKolesar|LKolesar]] 10:11, 2012 October 12 (CDT)
****Since this is a quality of care issue and should be monitored more, we will asked the ICU Task team, QI team and ICU director for further input.  If we need to raise the importance of collectors finding this information on chart, & if poor charting, how can ICU better document? Another option is to include it on new [[TISS28]].  Will follow up with email to Jodi Walker Tweed.-[[User:TOstryzniuk|Trish Ostryzniuk]] 19:03, 2012 October 11 (CDT)
*****See: [[Significant complications ICU]] & [[Significant complications medicine]].
******I think it should be included on the new tiss for 4 reasons:  1. the nurses are the ones to notice the skin condition and should be the ones to document this.  2.  The nurses are used to doing this already on the TISS. 3.It is not always well documented in the physicians notes. 4. It would be the easiest way to have this in the database because reviewing charts for this type of information is very time consuming!--[[User:LKolesar|LKolesar]] 10:09, 2012 October 12 (CDT)
 
====Medicine STB====
Medical wards have same problem as described by Pat S. Rarely, there will acctually be a very good note, by the 'skin and wound' nurse.[[User:ENagy|ENagy]] 15:45, 7 May 2010 (CDT)
 
=== VIC ===
====ICU VIC====
*?
 
====Medicine VIC====
*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
 
=== GRA ===
====ICU GRA====
*The nurses do a very good job of documenting ulcers under skin integrity on their daily flow sheet [[User:Lkaita|Lisa Kaita]] 12:25, 2017 May 18 (CDT)
 
====Medicine GRA====
*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.


=== CON ICU===
== When to use the generic dx ==
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.
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


=== OAK ICU===
== When to use the Unstageable dx ==
* At the Oaks information re: "skin-cwcm" condition is documented under CVS on the ICU Patient assessment record/flowsheet and/or IPN. If the area breaks down and requires a dressing the staff list the dressing site on the same flow sheet under "dressings"--I have not found that many since covering here.[[User:Mlaporte|Mlaporte]] 08:01, 11 May 2010 (CDT)
Wound bed can't be seen so true stage can't be determined.  


== See Also ==
==Start Dates==
*[[Significant complications medicine]]
*2017-Aug-24: unstageable
*[[Significant complications ICU]].
*2004-Jun: Med
*2004-Jan: ICU

Latest revision as of 17:29, 2020 July 28



for more info see: Wikipedia


Legacy Content

This page is about the pre-ICD10 diagnosis coding schema. See the ICD10 Diagnosis List, or the following for similar diagnoses in ICD10:Decubitus (pressure) ulcer, Stage I (surface reddening), Decubitus (pressure) ulcer, Stage II (to fascia, just under skin), Decubitus (pressure) ulcer, Stage III (deep, to but not including muscle), Decubitus (pressure) ulcer, stage not indicated, Decubitus (pressure) ulcer, Stage IV (involves muscle, tendon, or bone)

Click Expand to show legacy content.


edit dx infobox
Category/Organ
System:
Category: Dermatological Non-Infectious (old)

Type:

Category: Medical Problem (old)

Main Diagnosis: Ulcers - Decubitus only
Sub Diagnosis: ULCERS - DECUBITUS only
Diagnosis Code:
  • 94500 - Ulcers - Decubitus only (generic)
  • 94501 - Stage 1 - surface reddening of skin
  • 94502 - Stage 2 - just under skin
  • 94503 - Stage 3 - deep-to muscle
  • 94504 - Stage 4 - full layer-to bone
  • 94505 - Unstageable - can't see wound bed
Comorbid Diagnosis: No
Charlson Comorbid coding (pre ICD10): 0
Program:
Status:
Start Date: 2004

When to use the generic dx

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

When to use the Unstageable dx

Wound bed can't be seen so true stage can't be determined.

Start Dates

  • 2017-Aug-24: unstageable
  • 2004-Jun: Med
  • 2004-Jan: ICU