1. Ayello, Elizabeth A. PhD, RN, APRN,BC, CWOCN, FAPWCA, FAAN

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Q: How should I document the stage of a necrotic pressure ulcer that is entirely covered with hard black eschar?


A: Staging classifies the extent and depth of tissue destruction in a pressure ulcer. This requires visual inspection of the wound. In the United States, most clinicians use the staging system developed by the National Pressure Ulcer Advisory Panel (NPUAP) and included in the pressure ulcer guidelines from the Agency for Health Care Policy and Research (AHCPR; now the Agency for Healthcare Research and Quality).


How you stage a pressure ulcer covered with necrotic tissue, however, is not so straightforward. It depends on the care setting in which you practice. If you are caring for patients in an acute care or home care setting, you should follow the recommendations of the NPUAP and AHCPR. According to these guidelines, a pressure ulcer covered with necrotic tissue cannot be accurately staged until the eschar has been removed and the wound bed can be visualized. In this case, you would document the ulcer as "necrotic, unstageable." In addition, you should include a description of the pressure ulcer's other characteristics, such as length and width; presence or absence of exudate, odor, and pain; and the condition of the surrounding skin.


If you practice in a long-term-care setting, you must follow the guidelines of the Centers for Medicare & Medicaid Services (CMS). Under these guidelines, the Resident Assessment Instrument (RAI) user's manual, Version 2, gives specific instructions on how this type of pressure ulcer should be documented. If necrotic tissue covers the pressure ulcer (which would prevent adequate staging, as you cannot see the wound bed), the ulcer must be documented as Stage IV for MDS coding purposes. CMS recognizes and acknowledges that this is a departure from the NPUAP and the AHCPR recommendations. In addition, facilities are asked to follow the RAI directions for coding this type of pressure ulcer as Stage IV on the MDS, but not necessarily for treating it. It is acceptable to include a comprehensive description of the pressure ulcer in the narrative section of the resident's record.


The newly revised guidance for Tag F-314 pressure ulcers in long-term care became effective November 12, 2004, and can be accessed at


Selected References


Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of Pressure Ulcers. Clinical Practice Guideline, No. 15. AHCPR Publication No. 95-0652. Rockville, MD: Agency for Health Care Policy and Research; December 1994.


Department of Health and Human Services, Centers for Medicare & Medicaid Services. Guidance to surveyors for long-term care facilities. CMS Manual System Publication 100-07. Available at Accessed November 12, 2004.


National Pressure Ulcer Advisory Panel. National Pressure Ulcer Advisory Panel Staging Report. November 2003.


Panel on the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline, No. 3. AHCPR Publication No. 92-0047. Rockville, MD: Agency for Health Care Policy and Research; May 1992.