Wound Assessment Forms: Overview
The wound assessment tool consists of two forms that facilities will use to record weekly observations of resident pressure ulcers, resident risk factors, and other resident clinical information. Wound Assessment: Resident Information (Form 1) is used to record relevant clinical information about the resident. Wound Assessment: Ulcer Information (Form 2) is used to document a detailed assessment of a single pressure ulcer.
Each form is to be completed weekly by end users:
It is not unusual for a single resident to have multiple pressure ulcers and, rarely, more than one ulcer on the same ulcer site; therefore, there may be one Form 1 to many Form 2s for a single resident. Both forms are to be completed each week until all pressure ulcers are healed.
The user will complete Form 1 and Form 2 (one Form 2 for each ulcer) each week the resident has ulcer assessments. Once all ulcers are healed, the user discontinues use of both forms and they are stored in the resident's chart or medical record. An ulcer is considered resolved or healed when the user selects "healed"; as the Followup Ulcer Status on Form 2. The date of the report when the ulcer is deemed "healed"; is the Ulcer Heal Date.
If a resident with previously healed pressure ulcers develops a future ulcer, Form 1 and Form 2 are initiated once again as a set. Each data element selected on Form 1 and Form 2 is associated with a single resident identifier (resident ID), a uniquely identified ulcer (ulcer ID), and a date the form was completed (report date).
An ulcer is tracked from onset date to healed date; therefore, the system must assign a unique ulcer ID to each ulcer in the system.
New ulcers are ulcers identified since the previous report week; existing ulcers are known to the clinician, are being treated, and have been reported on previously. Healed ulcers are previously managed ulcers that have healed (Followup Ulcer Status = healed as found on Form 2). Facilities must be able to easily retrieve a list of residents with healed ulcers.
If Form 1 or Form 2 is completely filled and the user needs to continue documentation of ulcers, then another Form 1 and Form 2 need to be initiated.
Wound Assessment: Resident Information (Form 1)
Resident Name, Unique Identifier: as above, complete once/form/resident.
Information completed once per form:
- *Date of Admission (image only, captured on Census Management).
- *Resident Name (image only, captured during form association).
- *Resident ID (image only, captured during form association).
Required Weekly Information (Form 1):
- Report Date.
- Risk Factors.
Report Date. In addition to linking to a resident ID, the user must enter a report date each week the form is completed. The report date represents the date the user conducted the assessment of the ulcer; all information recorded on the form is associated with the clinical condition of the ulcer as observed on that assessment date.
Report Type. This is an image-only field. The user indicates initial or followup. If a new blank form is initiated as a continuation of previous reporting, then the user selects followup.
Risk Factors. The first time the user initiates a blank Form 1 the following information must be completed: report date, type, risk factors. Because ulcers may be reported on for several weeks it is important to include as many columns for "report week"; as the page size will allow. For example, the checked items for resident risk factors need to display at least once on the form for users to review each week. If a second Form 1 is needed for ongoing documentation of an ulcer, the user will be required to transpose all checked risk factor elements onto another Form 1 to continue wound documentation.
Risk Factors on Form 1 may not change from report week to report week. The user has the option, after the initial assessment, to select "no change in risk factors since last report date." If the user chooses "no change in risk factors since last report date,"; the system must carry forward the previously checked risk factor elements and associate elements with the current report date.
It is important for the end user to know how many risk factors a resident may have as it may be associated with the healing process; resident risk factors may change from week to week. Since it is important to determine associations, if any, between total number of resident risk factors for a single resident and total time to heal an ulcer (in days), the system must tore each risk factor and risk factor sum each week. Risk factor sum by resident currently displays on the report, "residents with existing pressure ulcer."; With the exception of "no change in risk factors since last report date"; option, which has a value of 0, all resident risk factor elements should be counted as 1.
The system will add the number of checked risk factors and store the Risk Factors Sum for reporting.
Refer to Data Elements, rows 11-37.
1.1.1. Risk factor sum shall display on reports; display risk factor sum associated with the selected report date. For example, if report date = week of June 11, 2007, display risk factor sum stored for report week June 11-17, 2007.
1.1.2. Each risk factor item shall be available to display as a discrete element on reports. For example, "acute changes in health status"; (row 21) indicator displays on Stagnant Ulcer Report (new report for PU Healing Module).
1.1.3. If "no change in risk factors since last report date"; is selected and there is no prior report date OR no previously stored risk factor items, assign risk factor sum 0 and display as discrepancy or documentation error.
1.1.4. If "no change in risk factor since last report date"; is selected and there are previously selected risk factor items associated with previous report date, carry forward previously selected risk factors and treat as current risk factor list. Carry forward previous risk factor sum and treat as current risk factor sum; associate each risk factor element and risk factor sum with new report date.
1.1.5. Requirement. If "no change in risk factor since last report date"; is selected but other risk factors elements are also selected, treat newly selected risk factor elements as current risk factors (i.e., ignore "no change in risk factor"; selection), update risk factor sum, and associate each risk factor and risk factor sum with report date.
1.1.6. If a new Form 2 is initiated as a continuation of previous documentation, risk factors are reselected, and there are no changes from the most recently stored risk factor values, treat as "no change in risk factors."
The system will assign a value to each line item listed in Risk Factors as follows: 0 to "no change in risk factors since last report date"; 1 to all remaining risk factor items in the list, including "other." The system will sum all selected risk factor items and store the sum as risk factor sum; the report date will be associated with each risk factor selected and risk factor sum.
Resident left facility since last report date. ER visits and hospital admissions may be associated with disruption in ulcer care and treatment and thus are associated with worsening ulcer status and longer healing time. The user will check the most appropriate option: resident left the facility during report week for hospital admission, resident left the facility during report week for ER visit, or resident returned from hospital admission during the report week. None or all options may be selected in any single report week.
Braden Score. The Braden score is a numeric value score = range 6-23. The user has the option to enter a value or leave the field blank. The Braden score will be used in analysis and research.
Wound Assessment: Ulcer Information (Form 2)
The user will complete the Wound Assessment: Ulcer Information (Form 2) each week to record ulcer-specific assessment information. The user will complete Form 2 for each ulcer being assessed during that report week. For example, if a resident has four unique ulcers, the user will complete four individual Form 2s and one Form 1 each week. The system will assign a unique ulcer identifier to each ulcer being assessed or reported. Each ulcer ID is linked to resident ID; one resident ID may have multiple ulcer IDs.
As with Form 1, the user should complete all sections of Form 2 once per week, but the user may start a form and finish documentation at a future date. It is also possible, although rare, for a user to complete 2 consecutive weeks of documentation at the same time.
Form 2 contains elements that are to be completed once per ulcer and elements that are to be completed weekly per ulcer.
Information completed once per ulcer:
- Resident Name (image only, captured during form association).
- Resident ID (image only, captured on form association).
- Date of Admission (image only, captured on Census Management).
- Date Ulcer Identified or Ulcer ID Date (image only, captured on Home Page) .
- Site of Ulcer (image only, captured on Home Page).
- Initial Ulcer Stage.
- Ulcer Occurrence.
- Ulcer Condition.
Information completed weekly per ulcer:
- Ulcer Dimensions (image only, captured on Home Page).
- Exudate Type.
- Drainage/Exudate Amount.
- Wound Edges.
- Peri Wound Area.
- Peripheral Tissue Edema.
- Peripheral Tissue Induration.
- Necrotic Tissue Type.
- Necrotic Tissue Amount.
- Adjunctive Therapies.
- Treatment Change.
- Followup Ulcer Status.
- Current Visualized Ulcer Stage.
- Resident Disposition.
Ulcer Dimensions. The user will record ulcer dimensions as ulcer length, width, and depth. There are two methods for measuring the ulcer length: clock method (C) and longest aspect of the wound (L).
Ulcer length displays on reports; it is necessary to store and display the length method on reports as C or L.
Calculate the ulcer size by multiplying ulcer length x ulcer width and assign a value to results as follows:
1 = <4 sq cm
2 = 4-16 sq cm
3 = 16.1-36 sq cm
4 = 36.1-80 sq cm
5 = >80 sq cm
1.1.7. The system shall store ulcer length method as either clock (C) or longest aspect (L).
1.1.8. The system shall store each ulcer dimension: length in cm, width in cm, and depth in cm.
1.1.9. The system shall compute ulcer size using length x width; store ulcer size in sq cm or surface area.
1.1.10. Once the ulcer size is calculated, the system shall assign a value to ulcer size according to the following parameters: 1 = < 4 sq cm; 2 = 4-16 sq cm; 3= 16.1-36 sq cm; 4 = 36.1-80 sq cm; 5 = >80 sq cm; store the assigned ulcer size value.
Some form categories, referred to as value categories, have a value assigned to each valid response (e.g., 1-6). Refer to Data Elements, rows 90-152 and 160-164.
- Ulcer Dimensions (length, width, depth; value assigned to size as noted above).
- Drainage/Exudate Type.
- Drainage/Exudate Amount.
- Wound Edges.
- Peripheral Wound Area.
- Peripheral Wound Edema.
- Peripheral Wound Induration.
- Necrotic Tissue Type.
- Necrotic Tissue Amount.
When the user selects a response from one of the value categories, the system must store the response (text) and the associated value. Responses from each value category are added and a category sum is calculated and stored. Category sum value will display in the table, Residents With Previously Reported Pressure Ulcers, in the Existing Pressure Ulcers Report.
All value categories have assigned value responses except "undermining."; This category provides the user with two choices: select value option 1-5 or record undermining direction and length. If the user records undermining direction and length, a value option will not be selected and undermining category value will be 0; therefore, if this value category response is missing, assign category value of 0.
1.1.11. The system shall store value (e.g., 1-6) for each value category, sum category values, and store sum as category sum.For example, if all categories have value 4, category sum value=48.
1.1.12. If there is no selection for one of the value categories, treat category value as 0.
Note that tunneling is not a value category but displays among value categories to adhere to use workflow. To record tunneling, the user enters a clock direction and length (cm). Users are accustomed to using the face of a clock on their current forms to describe the tunneling direction.
Each week the user will check all treatments that are in effect for the report week. As with the Risk Factors section of the form, if the user chooses "no change in treatments since last report date,"; the system must carry forward the previously checked treatment elements and associate these elements with the current report date. If the user does not select the option "no change in treatments since last report date,"; the user is expected to select treatment items currently in effect for the report week. The system will treat the newly selected items as the current list of treatments and associate each selected item with the report date.
It is important for the user to know which treatments were in effect at different points during the course of the ulcer care; each selected treatment is associated with a report date. Users will document more specific information about wound treatment and therapies. As an example, instead of selecting "irrigation,"; users will indicate type of irrigation: saline, soap and water, commercial wound cleanser product, or whirlpool.
1.1.13. If "no change in treatments since last report date"; is selected and there are previously selected treatment items associated with previous report date, carry forward previously selected treatment items, treat as current treatments, and associate treatment items with current report date.
1.1.14. If a treatment element previously selected is not carried forward or rechecked during the current report week, assign stop date to the item and assign current report date as stop date.
1.1.15. If "no change in treatments since last report date"; is selected but other treatment elements are also selected, ignore "no change in treatments since last report date"; selection and treat newly selected treatment elements as current treatment list, associate each treatment element with current report date, and include in discrepancy report.
It is important to analyze data at the item level (saline, soap and water, commercial wound cleanser products, whirlpool) and subcategory level (wound cleansing and irrigation) when analyzing data for associations between wound heal days and treatments.
Adjunctive Therapies and Interventions
Adjunctive therapies are not used by all facilities. As with Risk Factors and Treatments, the user will select adjunctive therapies in effect at the time of the report. Treat the selection "no change since last report date"; the same as with Risk Factors and Treatment categories.
Intervention elements should be selected each week; use same rules for the option "no change in interventions since last report date"; as used for same option in Risk Factors, Treatments, and Adjunctive Therapies.
Followup Ulcer Status
Each week the user will indicate whether the ulcer condition is improving, unchanged, worsened, or healed. If the ulcer is healed, associate the report date with healed status and store as heal date.
1.1.16. When followup ulcer status = healed, system shall assign report date as ulcer heal date.
Ulcers with status = healed display on "Healed Ulcer"; report only. For example, if an ulcer was assigned status "healed"; on July 18, 2007, ulcer will display in Healed Ulcers on July 23, 2007.
Current Visualized Ulcer Stage
Users will document the current ulcer stage each week. The initial ulcer stage is static; the current visualized ulcer stage may change from week to week. The user may choose one stage on each assessment or each report week: Stage I, Stage II, Stage III, Stage IV, or Unstageable. The highest visualized stage is reported on pressure ulcer reports. The highest visualized ulcer stage tells the user the worst stage over the course of the ulcer treatment.
1.1.17. The system must store the highest visualized ulcer stage reported from ulcer ID date to current report date; associate report date with highest ulcer stage.
Refer to the HIT Specifications Data Elements for instructions and valid input for the remaining sections of Form 2.
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Current as of July 2009
On-Time Pressure Ulcer Healing Project: Completing the Paper Forms for Electronic Paper-Based Data Capture. July 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/pressureulcerhealing/hitspecs.htm