Patient presents with a sacral ulcer, also documented as a pressure ulcer, pressure sore, decubitus ulcer, or bedsore, located on the sacrum.  Assessment reveals a stage [Insert Stage I-IV, unstageable, or deep tissue pressure injury] wound characterized by [Describe wound characteristics: size in centimeters length x width x depth, tissue type present e.g., granulation, slough, eschar, necrotic tissue, bone involvement, undermining, tunneling, exudate type and amount, surrounding skin condition e.g., erythema, induration, maceration, warmth].  The patient reports [Document patient's subjective complaints related to the ulcer: pain level and quality, itching, burning, odor].  Pain is managed with [Document pain management plan, including medications, dressings, and non-pharmacological interventions].  Surrounding skin is intact except as noted.  The etiology is suspected to be related to [Document contributing factors, e.g., immobility, pressure, shear, friction, moisture, malnutrition, impaired circulation, medical comorbidities such as diabetes, spinal cord injury, peripheral vascular disease].  The patient's current Braden Scale score is [Insert score] indicating a [Insert risk level: low, moderate, high] risk for pressure injury development.  Treatment plan includes [Document treatment plan: wound care regimen with specific dressing type and frequency, pressure redistribution measures e.g., specialized mattress, cushions, turning schedule, nutritional support, debridement if necessary, offloading techniques, consultation with wound care specialist, other relevant interventions].  Patient education provided on pressure ulcer prevention strategies including proper skin hygiene, regular repositioning, and importance of nutrition.  Follow-up scheduled for [Date/time] to reassess wound healing progress and adjust treatment plan as needed.  ICD-10 code L89.  CPT codes for wound care procedures will be documented separately based on services rendered.