Ulcers / Non-Pressure Ulcer / Pressure Ulcer

Progression

• When did disease process start
  
• Initial versus subsequent visit
  

Location

• Site and location-if pressure ulcer is on the patient's back, specify upper, lower, right, left, etc.

Acuity

• N/A
  

Name

• Non-pressure ulcer, pressure ulcer, decubitus
  
• Depth and stage-healing status
  
• Type-diabetic, varicose, stasis
  
• Infected, gangrene, cellulitis
  

Necessary Procedures

• Excisional, nonexcisional (excludes debridement performed prior to graft)
  

• Depth of debridement:

  • Skin breakdown-skin, subcutaneous tissue/fascia, fat tissue, necrosis of muscle or bone
    

  • Tool used for debridement procedure-scalpel, curette
    

Other

• Chronic venous hypertension with ulcer, POA (present on admissions) status of ulcers (especially pressure ulcers), stage
  

Why

• Link associated conditions-diabetes mellitus, malnutrition, PVD, etc.