Wound diagnoses

Scenario---pt. saw MD 8/2017, no mention of wound. SN is ordered to eval wound on toe which SN is saying is a pressure ulcer (on top of toe, from shoes). Is a discussion with MD re. the etiology and subsequent documentation on OASIS enough? Or must MD see the pt., document etiology and fax note? What are others doing in this situation?
Thank you


  • If nurse documents she confirmed the etiology with the MD, then it can be coded and reported in Oasis as such.
    I was recently advised by an editor of DH that even if an MD does not confirm an etiology - it can be reported in oasis as a pressure ulcer but not coded.

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