DiraChart MDS item reference
M0300DSection Mv1.20.1Manual page M-19
Stage 4 Pressure Ulcers
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RAI Manual v1.20.1Steps for Assessment
1. Perform head-to-toe assessment. Conduct a full body skin
assessment focusing on bony prominences and pressure-
bearing areas (sacrum, buttocks, heels, ankles, etc.).
2. For the purposes of coding, determine that the lesion being
assessed is primarily related to pressure and that other
conditions have been ruled out. If pressure is not the
primary cause, do not code here.
3. Identify all Stage 4 pressure ulcers currently present.
4. Identify the number of these pressure ulcers that were
present on admission/entry or reentry.
Manual page M-19RAI Manual v1.20.1Coding Instructions
for M0300D
M0300D1
•
Enter the number of pressure ulcers that are
currently present and whose deepest anatomical stage is
Stage 4.
•
Enter 0 if no Stage 4 pressure ulcers are present and skip to M0300E, Unstageable –
Non-removable dressing.
M0300D2
•
Enter the number of these Stage 4 pressure ulcers that were first noted at Stage 4 at
the time of admission/entry AND—for residents who are reentering the facility after a
hospital stay, enter the number of Stage 4 pressure ulcers that were acquired during the
hospitalization (i.e., the Stage 4 pressure ulcer was not acquired in the nursing facility
prior to admission to the hospital).
•
Enter 0 if no Stage 4 pressure ulcers were first noted at the time of admission/entry or
reentry.
DEFINITIONS
TUNNELING
A passage way of tissue
destruction under the skin
surface that has an opening
at the skin level from the
edge of the wound.
UNDERMINING
The destruction of tissue or
ulceration extending under
the skin edges (margins) so
that the pressure ulcer is
larger at its base than at the
skin surface.
M0300D: Stage 4 Pressure Ulcers (cont.)
Manual page M-19RAI Manual v1.20.1Coding Tips
•
The depth of a Stage 4 pressure ulcer varies by anatomical location. The bridge of the
nose, ear, occiput, and malleolus do not have subcutaneous tissue, and these ulcers can be
shallow.
•
Stage 4 pressure ulcers can extend into muscle and/or supporting structures (e.g., fascia,
tendon, or joint capsule) making osteomyelitis possible.
•
Exposed bone/tendon/muscle is visible or directly palpable.
•
Cartilage serves the same anatomical function as bone. Therefore, pressure ulcersthat
have exposed cartilage should be classified as a Stage 4.
•
Assessment of the pressure ulcer for tunneling and undermining is an important part of
theof the complete pressure ulcer assessment. Measurement of tunneling and undermining is notis
not recorded on the MDS, but should be assessed, monitored, and treated as part of the
comprehensive
re plan.
Manual page M-19 MDS item matrixAssessment Applicability
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