The items in this section document the risk, presence, appearance, and change of pressure ulcers/injuries. This section also notes other skin ulcers, wounds, or lesions, and documents some treatment categories related to skin injury or avoiding injury. It is important to recognize and evaluate each resident’s risk factors and to identify and evaluate all areas at risk of constant pressure. A complete assessment of skin is essential to an effective pressure ulcer/injury prevention and skin treatment program. Be certain to include in the assessment process, a holistic approach. It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound.
Note: This course has been updated to reflect the RAI changes effective 10/1/2023.
The items in this section document the risk, presence, appearance, and change of pressure ulcers/injuries. This section also notes other skin ulcers, wounds, or lesions, and documents some treatment categories related to skin injury or avoiding injury. It is important to recognize and evaluate each resident’s risk factors and to identify and evaluate all areas at risk of constant pressure. A complete assessment of skin is essential to an effective pressure ulcer/injury prevention and skin treatment program. Be certain to include in the assessment process, a holistic approach. It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound. Note: This course has been updated to reflect the RAI changes effective 10/1/2023.
In support of improving patient care, Relias LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Arkansas State Board Of Nursing Approved Continuing Education program (CEBroker Provider #50-290).
Provider approved by the California Board of Registered Nursing, CEP# 13791
Nurses will receive 1.25 contact hours for participating in this course.
District of Columbia Board of Nursing Approved Continuing Education program (CEBroker Provider #50-290).
Florida Board of Nursing (CEBroker Provider #50-290)
Georgia Board of Nursing (CEBroker Provider #50-290)
Kentucky Board of Nursing (CEBroker Provider #50-290)
Nurses will receive 1.25 contact hours for participating in this course.
Mississippi Board of Nursing (CEBroker Provider #50-290)
New Mexico Board of Nursing (CEBroker Provider #50-290)
North Dakota Board of Nursing (CEBroker Provider #50-290)
South Carolina Board of Nursing (CEBroker Provider #50-290)
West Virginia Board of Registered Nursing (CEBroker Provider #50-290)
Outline:
Section 1: Introduction
About This Course
Learning Objectives
Section 2. M0100 - Determination of Pressure Ulcer/Injury Risk
Rationale
Assessment
Instructions
Definitions
Section 3 M0150 – Risk of Pressure Ulcers/Injuries
Rationale
Assessment
Instructions
Section 4: M0210 - Unhealed Pressure Ulcers/Injuries
Rationale
Assessment
Instructions
Tips
Definitions
Section 5: M0300 - Current Number of Unhealed Pressure Ulcers/Injuries
Assessment
Examples
Definitions
Section 6: M0300A - Stage 1 Pressure Injuries
Rationale
Assessment
Instructions
Definitions
Section 7: M0300B - Stage 2 Pressure Ulcers
Rationale
Assessment
Instructions
Tips
Definitions
Section 8: M0300C - Stage 3 Pressure Ulcers
Rationale
Assessment
Instructions
Coding Tips
Examples
Definitions
Section 9: M0300D - Stage 4 Pressure Ulcers
Rationale
Assessment
Instructions
Tips
Definitions
Section 10: M0300E - Unstageable Pressure Ulcers/Injuries – Non-Removable Dressing/Device
Rationale
Assessment
Instructions
Definitions
Section 11: M0300F - Unstageable Pressure Ulcers Slough and/or Eschar
Rationale
Steps for Assessment
Coding Instructions
Coding Tips
Examples
Definitions
Section 12: M0300G - Unstageable Pressure Injuries Related to Deep Tissue Injury
Rationale
Steps for Assessment
Coding Instructions
Coding Tips
Example
Definitions
Section 13: M1030 – Number of Venous and Arterial Ulcers
Rationale
Steps for Assessment
Coding Instructions
Coding Tips
Example
Definitions
Section 14: M1040 - Other Ulcers, Wounds and Skin Problems
Rationale
Steps for Assessment
Coding Instructions
Coding Tips
Examples
Definitions
Section 15: M1200 - Skin and Ulcer/Injury Treatments
Rationale
Steps for Assessment
Coding Instructions
Coding Tips
Examples
Definitions
Section 16: Conclusion
Course Contributors
Reference
Reviewer: Laura Anderson, MSN RN, WCCRon Orth obtained a nursing degree from Milwaukee Area Technical College in 1985 and a B. A. in Health Care Administration from Concordia University in 1996. Mr. Orth possesses over 30 years of nursing experience with over 20 of those in the Skilled Nursing industry. Mr. Orth has extensive experience in teaching Medicare regulations to healthcare providers both in the US and internationally. Mr. Orth is currently the Director of Curriculum Design for the Acute and Post-acute Care verticals at Relias. Ron has also successfully completed the Infection Control Officer training through the AHCA.
Laura Anderson is currently a Curriculum Designer for Post-Acute Care at Relias and manages a team of subject matter expert writers. Previously, she was a Director of Nursing, Clinical Informatics Nurse, Senior Clinical Consultant, Nurse Auditor, Business Office Manager, Clinical Author, and Wound Care Nurse. Laura has dedicated more than 20 years of professional practice to the skilled nursing and long-term care industry. After receiving her Masters of Science in nursing with an emphasis in geriatrics, mental health, and education from the University of Wisconsin-Madison, she continued to pursue additional training in wound care. Laura is passionate about providing quality, resident-centered care that encompasses the whole person.
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