Long-Term Care Survey Alert

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