SOC nonobservable Pressure injury

lschouten

At SOC have a dressing on pressure ulcer so the oasis is marked as unstageable, however in the H & P it is staged as a stage 2. SN observed the wound 2 days later and confirms stage 2 (but not the same assessing SN). Do you could it as an unstageabe?

MariaB

a non-visible wound is not an unstageable wound... you will need to re-code it to the correct stage.

cpiemonte@caretenders.com

I would double check the accuracy of your response- now that we are following OASIS C2 guidelines. The new convention is that wounds are assessed as close to SOC/ROC as possible and the status of the pressure ulcer needs to correspond to the visual assessment by the skilled clinician on the date of the assessment. A known ulcer can be unstageable when there is a non-removable dressing/device.
The guidance states:
The general standard of practice for patients starting or resuming care is that patient assessments are completed beginning as close to the actual time of SOC/ROC as possible. If a pressure ulcer that is identified on the SOC date increases in numerical stage (worsens)within the assessment time frame, the initial stage of the ulcer would be reported in M1311 at the SOC.

lschouten

But how do you code the M1021? Do you code it as a stage 2 based on the H & P?