Skin
Improving Physician Documentation Specificity
Increasing physician knowledge and proficiency with Advocate Health Care's clinical information systems.
Document site and laterality
- Lower leg
- Foot
- Heel
If non-pressure ulcer
- Document type
- Non-healing
- Chronic
- Stasis
- Diabetic
- Atherosclerotic
- Document associated infection or gangrene
If pressure ulcer (decubitus)
- Document if present on admission
- Document stage
| Stage | Description |
|---|---|
| 1 | Pre-ulcer, skin changes limited to persistent focal edema |
| 2 | Abrasion, blister, partial thickness skin loss involving epidermis and/or dermis |
| 3 | Full thickness skin loss involving damage or necrosis of subcutaneous tissue |
| 4 | Necrosis of soft tissues through to underlying muscle, tendon or bone |
| Unstageable |
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.
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Advocate Physician Informatics
Increasing physician knowledge and proficiency with Advocate Health Care's clinical information systems.
