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  1. Zulkowski, Karen M. DNS, RN, CWS
  2. Tellez, Robin MS/HSA, RN, CWS
  3. van Rijswijk, Lia BSN, RN, CWCN, COCN


The Minimum Data Set is designed to be the assessment instrument used in all long-term-care facilities receiving federal funds for Medicare and Medicaid. However, Section M: Skin Condition is one of the most challenging sections to complete when trying to match the Minimum Data Set documentation with the true clinical picture. If wounds are not adequately assessed and documented, outcomes of care cannot be evaluated, and treatment and prevention plans will be inadequate. This may result in less than optimal outcomes and possible lawsuits for inadequate care against both the caregiver and facility. The purpose of this article is to provide examples of medical record documentation necessary to support the Minimum Data Set assessment.