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Manual page M-1DiraChart MDS item reference
M0100ASection Mv1.20.1Manual page M-1
Risk determination: has ulcer, scar, or dressing
This item is referenced against CMS MDS source materials. Verify coding against the current CMS RAI Manual, item set instructions, and facility documentation before submission.
Quick coding
Answer Codes
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Manual page M-1Item-specific instructions
Coding Guidance
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Steps for Assessment
1. Review the medical record, including skin care flow sheets
or other skin tracking forms, nurses’ notes, and pressure
ulcer/injury risk assessments.
2. Speak with the treatment nurse and direct care staff on all
shifts to confirm conclusions from the medical record
review and observations of the resident.
3. Examine the resident and determine whether any ulcers,
injuries, scars, or non-removable dressings/devices are
present. Assess key areas for pressure ulcer/injury
development (e.g., sacrum, coccyx, trochanters, ischial
tuberosities, and heels). Also assess bony prominences (e.g.,
elbows and ankles) and skin that is under braces or
subjected to pressure (e.g., ears from oxygen tubing).
Coding Instructions
For this item, check all that apply:
•
Check A if resident has a Stage 1 or greater
pressure ulcer/injury, a scar over bony
prominence, or a non-removable dressing/
device. Review descriptions of pressure
ulcers/injuries and information obtained during physical
examination and medical record review.
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