Stage 2 per physician but....

Pt has a pressure injury on heel . Dr says its a stage 2 she has been debriding but when SN goes out to do assessment its very dark and no wound bed surface is visible. I still want to code it and score it as a 2 because physician who is debriding it calls it a 2 am I correct or is it unstagable she is a wound care physician.


  • As long as the physician has stated it is a pressure ulcer, the nurse can stage and you can code accordingly.

    JoAnn Noel RN, MSN, COS-C, HCS-D
    Director of Regulation

    Valley Health Home Health
    333 W. Cork Street
    Winchester, VA 22601
  • Per WOCN guidelines, stage 2 pressure ulcers do not have avascular tissue, if the wound has dead tissue that needs to be debrided it can't be a stage 2. I would ask the physician why she is calling it a 2 if it has to be avascular/necrotic tissue.

  • Stage 2's as mentioned by linda smith do not have avascular tissue. If it has eschar, slough - it is minimally a stage 3 once wound is debrieded. I would make this an unstageable PU, because you will get dinged for a worsened PU on next oasis assessment once the eschar releases or wound is debrieded. The MD MUST confirm that the wound is a PU, but it is completely within the scope of the RN's practice to stage the wound and determine it is unstageable.

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