Documenting tissue type with a stage 2 pressure injury

by Dolo the nurse Dolo the nurse (New) New

Hi! I’ve recently returned to wound care in a LTC facility. When the new npuap staging definitions were released, I was working in a different role. I’m having trouble with how tissue type should be documented for a stage 2. Clearly, this is a wound bed without slough, necrosis or granulation tissue. My question is should I describe as epithelial tissue even if it’s open and has drainage? After doing extensive research on my own I still can’t find an answer. Exposed dermis seems the most appropriate but the MDS doesn’t have a box for that. Any suggestions would be greatly appreciated.

michksmith14, BSN, RN

Specializes in CEN. Has 8 years experience. 85 Posts

I've seen this tissue called "primary tissue" by our wound care MD. I don't think it can be called epithelial as an open wound, that certainly would be an issue with coding/insurance if it is technically deemed healed with the epithelialized diagnosis code.