Assess the perineum/genitalia in the context of the skilled reason and document the judgment:
The perineal and genital skin: moisture-associated dermatitis (erythema, denudement in a moisture pattern) versus a pressure injury, and any breakdown’s location, size, and characteristics (route staging to Skin).
Contributing moisture (incontinence, drainage) and pressure, the containment/barrier plan in use, and catheter-associated genital skin (pressure, hygiene).
Signs of infection — local (increasing erythema, purulence, odor) and, critically, necrotizing infection (rapidly spreading erythema, dusky/black skin, crepitus, pain out of proportion, systemic signs).
MDS-supportive data
Perineal skin, moisture-associated dermatitis, and wounds are coded in MDS Section M, incontinence in Section H, and relevant diagnoses in Section I. The record must document the perineal skin/wound assessment and the specialized care so the MDS is supported.
