Facility _____________________ Patient name _______________ Date_______________
Date of admission or readmission __________
Date of last assessment __________________
Skin condition upon admission/readmission: (Full skin audit)
Pressure ulcers located (stage): _______________________
Other wounds, skin problems (location): _________________
Bruising: ___________
(See attached pictures)
Skin status today: __________________________________________
Skin intact _____ Pressure ulcers: location and stage: __________________________________________________________
Other wounds (type/location) __________________________________
__________________________________________________________
Standardized Preventive Care Program
Pressure-reduction surfaces in place. Date ____ Circle all that apply: Bed, chair, wheelchair
Hydration status ________________ Average daily fluid intake: ____________
Any prior Hx of dehydration noted on MDS? Yes __ No_____ If so, date of MDS____
Diet _________________ Weight loss in past week? Yes___ No____Percentage of weight_________ Underweight? Yes___ No___ Obese? Yes___ No___
Diet ________ Supplements? Yes___ No___ Type__________________
Continence status and care_______________________________________
Comorbidities and Mobility
Diabetes mellitus___Cardiovascular___Peripheral neuropathy_____ Other ______________________________________________________________
Nonambulatory____ Bed bound ____ Wheelchair bound____
Requires help with bed mobility_____ Requires assistance with transfer ____
Specialized Prevention
Turning and repositioning interventions? Yes ___ No ____
Describe _____________________________________________________
Special diet? Type ____________ Date of dietary consultation_____
Rehabilitation therapy Yes ____ No_____ (if yes, see attached rehabilitation treatment plan)
Restorative nursing interventions? Yes ___ No____ (If yes, see attached restorative nursing care plan and progress report)
Special skin care regimen? Describe______________________________
Pressure-relieving mattress for immobile patient? Yes___ No___ Date provided_____
Wound Care
Name of practitioner(s) who diagnosed wound as true pressure ulcer___________________________________ Date ________
Wound care treatment and specialized interventions (see attached care plan)
_________________________________________________________
Change in wound since last assessment? Describe_________________________
__________________________________________________________________
Source: Eli Research
