Form 1: Wound Assessment Resident Risk Factors

On-Time Pressure Ulcer Healing Project

Describes new tools to document pressure ulcer healing and treatments as part of the On-Time Quality Improvement Program.
Patient ID:

Facility Name  _______________________________________

Date of Admission: __  __ /__  __ /__  __ __ __
                                    M  M      D    D    Y     Y   Y    Y

Resident ID: _____________________________________

Report DateM|M|D|DM|M|D|DM|M|D|DM|M|D|DM|M|D|DM|M|D|D
Report Type: Please select the report type: (Initial (I), Followup (F))IFIFIFIFIFIF
Risk Factors
1No change in risk factors since last report date (If marked, do not mark additional risk factors)      
2Moribund (actively dying, end-stage diagnosis)      
3Impaired/decreased mobility and decreased functional ability      
4Physically restrained      
5Comorbid conditions (having 2 or more chronic diseases or conditions simultaneously such as diabetes, cardiovascular, pulmonary, or renal disease)      
6Impaired, diffuse or localized blood flow; generalized atherosclerosis or LE arterial insufficiency; PVD, chronic edema, smoking      
7Refusal of some aspects of care/treatment      
8Cognitive impairment      
9Exposure of skin to urinary and fecal incontinence, perspiration, drainage or weeping      
10Poor or reduced meal intake      
11Poor or reduced fluid intake      
12Healed ulcer; history of healed pressure ulcer stage I      
13Healed ulcer; history of healed pressure ulcer stage II      
14Healed ulcer; history of healed pressure ulcer stage III      
15Healed ulcer; history of healed pressure ulcer stage IV      
16Healed ulcer; history of healed pressure ulcer stage unknown      
17At risk for friction or shearing during repositioning, including repetitive movements by resident      
18Admitted with potential for deep tissue injury secondary to preadmission factors such as prolonged bed rest, surgery; signs of skin impairment on admission      
19Neuropathy      
20Disease or drug related, including immunosuppressants, such as steroids that may affect wound healing; anticoagulant therapy      
21Medically necessary interventions, e.g. cast, braces, O2 tubing, foley catheter, elevated HOB      
22Acute changes in health status      
23Inpatient/Outpatient hospitalization in last 90 days      
24ER visit within last 90 days      
25Current pressure ulcer      
26Other      
Other Clinical Information
1Resident weight
Enter most recent resident weight if new weight obtained since last report date
      
2Resident left facility since last report date
If resident left the facility during the reporting period, please mark the appropriate reason(s): Hospital admission or ER visit. If this process does not apply to your facility, e.g. if all residents who leave building are discharged, please leave blank.
      
3Resident left facility during report week for Hospital Admission      
4Resident left facility during report week for ER Visit      
5Resident returned from hospital admission during report week      
6Braden Score: (optional) Please write Braden Score at the time of the report, if available            
Initials

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Page last reviewed July 2009
Internet Citation: Form 1: Wound Assessment Resident Risk Factors: On-Time Pressure Ulcer Healing Project. July 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcerhealing/waform1.html