Form 2: Wound Assessment: Ulcer Information (continued)

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.
Report DateM|M|D|DM|M|D|DM|M|D|DM|M|D|DM|M|D|DM|M|D|D
Treatments (check all that apply)
No change since last report date; treatment remains appropriate      
Antimicrobials 1: acetic acid 2: Dakin's or hydrogel acid
3: povidone iodine or Betadine 4: Other
Barrier cream      
Cleansing & Irrigation:
   Commercial wound cleanser products
   Soap and Water      
Calcium alginates
   Foam dressing      
   Gauze dressing - Dry      
   Gauze dressing - Moist      
   Hydrogel amorphous      
   Hydrogel impregnated gauze      
   Hydrogel sheet dressing      
   Hydrocolloid dressing      
   Petroleum impregnated gauze dressing      
   Transparent film dressing      
Open to air      
Adjunctive Therapies (check all that apply)
No change since last report date; adjunctive therapy appropriate      
Cytokine growth factors      
Electrical stimulation      
Hyperbaric oxygen      
Low-energy laser radiation      
Negative pressure wound therapy (NPWT)      
Low frequency (L)
   High frequency (H)      
Ultraviolet radiation      
Interventions ( check all that apply)
No change since last report date: interventions remain appropriate      
Intervention to maintain / improve nutrition & hydration status      
Monitoring of skin integrity and tissue tolerance      
Minimize exposure to moisture, including but not limited to, fecal and urinary contamination, perspiration      
Minimize risk for sheer and friction      
Monitor protein intake, calorie intake, vitamin & mineral supplements      
Monitor for labs as ordered by physician or facility protocol, including but not limited to, Hb, albumin, serum transferrin      
Support Surfaces for Bed:
   Air-fluidized surface
   Dynamic/alternating pressure surface      
   Low-air-loss surface      
   Replacement mattresses      
   Static support      
Support Surfaces for WC:
   Air cushions
   Fluid-filled or gel cushions      
   Foam cushions      
   Combination cushions      
Other Support Surfaces: Heel boots      
Teaching: resident teaching to redistribute pressure; reposition & offloading; risks & benefits      
Turning and proper positioning: turning schedule      
Vitamins and Supplements:
   Nutritional supplement      
   Vitamin C      
Consultation (check all that apply)
ET nurse      
Plastics clinic/surgical clinic      
Rehab/in-house physical therapy      
Wound clinic      
Wound nurse consultant      
Followup Ulcer Status
No change      
Current Visualized Ulcer Stage
The facility acknowledges that NPUAC and WOCN recommend not to downstage pressure ulcers. However, to comply with Medicare and Medicaid documentation requirements, pressure ulcer will be staged as visualized at the time of each reporting period. If resident is discharged, enter stage of ulcer at time of discharge.      
Stage I      
Stage II      
Stage III      
Stage IV      
Resident Disposition
Resident discharged since last report date      
Resident expired since last report date      

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Page last reviewed October 2014
Internet Citation: Form 2: Wound Assessment: Ulcer Information (continued): On-Time Pressure Ulcer Healing Project. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.