Sacral pressure ulcer documented.  Patient presents with a stage [Roman numeral stage I-IV] pressure injury located on the sacrum.  The wound bed is [describe appearance, e.g., erythematous, non-blanchable, with eschar, slough, granulation tissue] and measures [length] x [width] x [depth] cm.  Surrounding skin is [describe periwound skin, e.g., intact, macerated, indurated, with erythema].  Patient reports [patient's subjective complaint, e.g., pain, itching, burning, no discomfort].  Pain assessed using the [pain scale used] scale and rated as [pain score].  Wound edges are [describe edges, e.g., defined, undefined, rolled, attached].  Drainage is [describe drainage, e.g., absent, serous, serosanguineous, purulent, amount].  Odor is [describe odor, e.g., absent, present, foul].  Assessment suggests this pressure injury is related to [etiological factors, e.g., immobility, moisture, shear, friction].  Diagnosis: Pressure ulcer, sacral, stage [Roman numeral stage I-IV].  Plan:  Wound care initiated with [describe wound care, e.g., debridement, dressing type, frequency of dressing changes].  Pressure redistribution measures implemented including [describe measures, e.g., specialized mattress, turning schedule].  Nutritional assessment recommended.  Patient education provided regarding pressure ulcer prevention, wound care, and importance of repositioning.  Follow-up scheduled in [duration] for wound reassessment and ongoing care.  ICD-10 code: L89.152.