Assess risk on admission and per policy, and for each wound capture a full serial description:
Risk: a validated scale (e.g., Braden) plus mobility, nutrition/hydration, moisture/continence, perfusion, and sensory status.
Each wound: etiology (pressure vs moisture vs arterial/venous/diabetic), NPIAP stage (1–4, unstageable, deep-tissue injury), measurements (length × width × depth; undermining/tunneling by clock position), wound-bed composition %, exudate, periwound, edges, odor, and pain.
Present-on-admission status on admission, and comparison to the prior weekly measurement thereafter.
MDS-supportive data
Pressure ulcers/injuries are coded in MDS Section M by stage, with present-on-admission status and healing; the record must document stage, measurements, and POA status so Section M is supported (F641). Immobility and function link to Section GG.
