Pressure Ulcer Query

Snuggs105

Good Morning All,

New CDI here looking for advice on how to set up a query for pressure ulcers with conflicting documentation.

While in the ER patient was seen for an ICU consult which noted: Chronic non stageable deep ulcer at right gluteal area, stage 2  ulcer at left gluteal area , has blisters in the lateral left thigh, superficial blisters in B/L scrotum

He had a Wound Consult with a Wound RN four days later who states:

#1 Left Lateral thigh- unstageable 4.2cm x 3.7cm

#2 Left Lateral thigh - Partial thickness 2.1cm x 2.5cm

Sacrum- Partial thickness 4.0cm x 3.0cm

Right Ischium Full thickness 5.6 cm x 4.5cm x 4.0 cm

Right Anterior Thigh - unstageable 3.6cm x 2.4 cm

Scrotum - moisture associated dermatitis

The Floor RN's caring for the patient state the following POA:  SDTI on Left upper back, Unstageable Proximal Ischium, Unstageable Midline Knee, Partial Thickness Medial Sacrum, Stage 2 Scrotum, Stage 2 left thigh.

The attending DR only  AKA stump ulcers covered with duoderm

I am not sure how to set up this query. Would you just ask which do you agree with? ICU vs Woc RN or Other? or would you list each ulcer? How would you ask POA status in the same query since the Wound RN came 4 days later. Am I over thinking this?

Thank you for your help!

kirwin@medinamemorial.org

I am also new to CDI, but I had a similar situation. I queried the Attending by listing the sites of all documented wounds and check boxes under each site for Pressure Injury, dimensions, POA, etc.

drew.siegel205

The issue with the pressure ulcer is that they must be confirmed by a clinician as being present. The stages can be captured from Wound Care/RN's.
Were the pressure ulcers identified in the ED documented by a clinician? If  so, you might send a confirmation query to the attending asking if the pressure ulcers as documented by ED/ICU physician were present or ruled-out.