CPC Guidelines Practice Test

The primary responsibility for documenting BMI, non-pressure ulcers, and pressure ulcer stages typically falls to a nurse. Nurses are trained to perform assessments that include measuring a patient's body mass index (BMI) and physical assessments of the skin, which encompass identifying and staging pressure ulcers as part of their role in providing patient care.

While the patient's primary provider may have an overall responsibility for the patient's health management and may need to review this information, the actual documentation and detailed assessment regarding these specific elements are generally completed by nurses, who are on the front lines of patient interaction.

Additionally, a specialist physician may focus more on treating complex cases rather than recording these specific metrics, and family members do not have a clinical role in documentation. Thus, the key responsibilities for documenting such clinical notes lie with nursing staff who have the necessary training and authority to perform these assessments.