Wounds Pressure Injury

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General Section

SKILLED DOCUMENTATION GUIDELINES — EXPANDED

DiraChart · Clinical Reference · Read-only baseline inherited by all agencies

Body System Reference · 2.21

Wounds / Pressure Injury

Existing wounds and pressure injuries, and the skilled care of them. Diagnoses commonly routed here: pressure injury (stages 1–4, unstageable, deep-tissue), surgical wound, diabetic/neuropathic foot ulcer, venous and arterial ulcers, skin tear, and moisture-associated skin damage. Prevention and intact-skin risk live in Integumentary; etiology by perfusion lives in Peripheral Vascular.

Module code

SYS-WOUNDS

Version

1.0 · Population: Adult · Authoring level: DiraChart (read-only baseline; agencies may append)

Used alongside

Integumentary / Skin (risk & intact-skin exam) · Peripheral Vascular (arterial/venous etiology) · Endocrine / Metabolic + Diabetes overlay (diabetic foot) · Anticoagulation overlay (bleeding wound) · Vital Signs

How to use this module

This module supplies the complete assessment, measurement, staging, and skilled care of existing wounds and pressure injuries, and the language that proves the care required a licensed nurse. Each narrative is a structured example to be edited to the wound actually assessed and the patient’s specific orders — not a phrase to copy. Prevention of breakdown and the intact-skin risk exam are documented in Integumentary and cross-referenced here.

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