Q&A: Querying for pressure injuries with proper documentation

Article Overview

This article discusses pressure-injury documentation review from a CDI perspective and addresses the relationship between nursing observations, provider diagnosis, and wound staging or depth documentation. It is aimed at CDI professionals, coders, nurses, and providers who need a clearer understanding of documentation responsibilities, query considerations, and education around wound characterization and reporting. The piece also notes the role of wound care referral and the importance of accurate clinical documentation before code assignment.