Good afternoon.
 
I was wondering if you could help me with this question. I see that pressure injuries are not considered hospital acquired if they're documented within 24 hours of admission (for Stage 2,3,4) or 72 hours of admission (for DTPI).
 
However, I see no specific wording that defines what "documented" means. Does it require a mere mention of the wound in the EHR (e.g. "discoloration on left foot")? Does it require specific descriptors of wound bed appearance? Measurements? Photos? General anatomical location or a specific one (e.g. "left leg" versus "left lateral malleolus")?
 
I am a wound care nurse, and I would like to establish a better protocol for my facility to document all present on arrival wounds properly. However, I like to cite my work, and I would love to see specific wording quoted from an official authority (e.g CMS) explicitly defining what requirements must be met for wound to be considered documented on admission.