How Should Medical Professionals Document a Healing Bed Sore?

By Nursing Home Law Center

Healing Bedsore DocumentationWhen an elderly person receives treatment for a bed sore, doctors classify the injury based on how deep and severe the wounds are. The treatment process can be very lengthy and painful. However, doctors tend to lower the classification of the wound as the patient recovers. While this practice may seem logical, reverse staging can have adverse effects on bed sore patients.

What are the Different Stages of Bed Sores?

Bed sores, also known as pressure ulcers, receive classifications from doctors to describe their severity. The four stages detail what damage the sores do to the human body and the appropriate course of treatment for the patient.

  • Stage I is the least severe stage of bed sores. Usually, they only affect the outer layer of skin and no open wound is present. The patient may have pain, itching, redness, and warmth in the area. Stage I bed sores usually go away within 2 or 3 days and require simple cleaning and repositioning.
  • Stage II bed sores cause an open wound. Patients with stage II sores usually experience swelling, warmth, redness, pain, and pus excretion. Stage II sores can recover between 3 days to 3 weeks and require pain relievers, dressing, and cleaning.
  • Stage III sores affect the fat tissue of the skin. Patients can experience pain, foul smelling open wounds, pus, warmth, and dead or dying tissue. Stage III sores require between 1 to 4 months of treatment, antibiotics, and dead tissue removal.
  • Stage IV is the most severe stage of bed sores, affecting the muscles, bones, and tendons. Patients will experience deep sores, black skin, and infection symptoms such as pus, warmth, and redness. Stage IV sores' recovery times take 3 months up to several years. Treatments include immediate cleaning or surgery.

In addition, bed sores may be "Unstageable" or "Suspected Deep Tissue Injury" (SDTI). A wound is unstageable if a doctor cannot see the bottom of the sore, and therefore cannot know how deep the wound is. If the sore looks like a Stage I or II but has Stage III or IV damage, the doctor will classify the wound as SDTI.

What is Reverse Staging?

Sometimes, doctors re-classify bed sores as they receive treatment. A Stage IV wound that slowly heals may receive a Stage III classification after a few months, a Stage II classification after another few months, and a Stage I classification when the wound is close to healing. However, this practice does not accurately describe the wound's damage.

Despite an outward appearance that a bed sore may be healing, the sores do not completely heal. A patient cannot completely regain the tissue, muscle, and skin lost to significant bed sore damage. As a result, re-classifying the sore to a lower stage does not accurately characterize what is happening with the injury.

Dangers of Reverse Staging for Bed Sores

Rather than using a reverse staging description for bed sore diagnosis, professionals in long-term care facilities such as nursing homes and hospitals should note the initial classification and avoid re-categorization. In addition, medical professionals should use detailed written descriptors to describe the size of the bed sore and its progression.

The benefit of using descriptors, rather than reverse staging, to document a healing bed sore is accuracy. Staging is accurate to a degree, but doctors should accompany stage descriptions with detailed notes. Re-categorizing a stage 4 bed sore to a lower stage, for example, can misrepresent the severity of the injuries.

Advanced bed sores can never regenerate the muscle, skin, and fat lost to the original wound. In addition, the doctors may not be able to detect deeper damage underneath a healed wound. Descriptors provide a more precise picture of the patient's bed sore history, allowing for a more accurate and customized care plan.

If you need an attorney for your loved one suffering from bed sore injuries, contact Nursing Home Law Center LLC today.


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