Hi Melissa,
The NPIAP paper is well written and when documenting your "Impression" part of the clinical note, discuss why
and what factors you believe makes this a COVID related skin alteration and not a "typical" DTI. Feel free to reference the NPIAP paper. If the medical record gets reviewed by a regulator or payor - even 3 or 4 years from now - you'll be able to defend your diagnosis.
My own experience (anecdotal) is that these issue look very much like DTIs, but their appearance seems too late in the patient's course of care without any identifying precipitating factor for a DTI (stable BP, no anemia or hypoxia, no longer on pressors, etc.) and..many never fully evolve!
WoundCon ( a free online wound symposium that offers CE for free - next symposium is in July ...WoundCon.com to register) will be having two great lectures on COVID wounds - the keynote is pressure injury in patients and providers and the other one is is by Kara Couch - who is presenting on several skin manifestations seen in COVID patients...worth signing up for!
Thanks!
Cathy

Hello, that was some very informative information. If there possible mixed etiology, which is the " diagnosis" ? Thank you

As the NPIAP paper and Cathy mentioned, these DTI-like lesions on COVID patients may well be due to covid-related clotting and not due to pressure/shear. Before diagnosing them as DTI or mixed etiology (e.g. DTI and covid skin manifestations) it'd be important to be able to identify pressure/shear as the etiology. According to the NPIAP, if the lesion is on a non-pressure bearing surface and in the absence of pressure/shear, these should not be classified as pressure injury. If the lesion is on a pressure bearing surface or has been subjected to shear, further investigation needs to be carried out. As Cathy stated, history is important, such as timing/development of the lesions, presence of DTI precipitating factors, whether adequate preventative interventions have been in place. NPIP recommends palpating the lesions to detect differences in tissue consistency and temperature to rule out concomitant DTI. A skin biopsy would show frank necrosis of skin, fat, and muscle for DTI, while it'd show clotting for covid skin manifestations. My assumption is that after careful investigation, in many cases it'd be possible to tell whether the lesion is a DTI or potential skin manifestation from COVID-19. 

Melissa,
I, too, wish diagnosing problem was always clear..but often it is not. If you can't tell the etiology - just say so in your notes, then re-evaluate the patient in 48 hours and see if you can then discern a definitive diagnosis. With COVID and without a biopsy, one will never know the true origin of the wound...It is OK in the documentation to say that in your opinion and in discussion with the patient and family that risks associated with a biopsy are greater than not having results - especially if it will not change your plan of care.