Instructions To Complete Wound Assessment Forms

On-Time Pressure Ulcer Healing Project

I.    General Instructions
II.   Documentation Forms
III. Form-Specific Instructions for Wound Assessment: Resident Information (Form 1)
IV.  Form-Specific Instructions for Wound Assessment: Ulcer Information (Form 2) 

I. General Instructions

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. These instructions are intended for users of the Digital Pen technology. A clinician records wound assessment information on a digitized form using a digital pen.

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II. Documentation Forms

  1. The Wound Assessment: Resident Information form (Resident Information Form) is a one-page form used to record relevant clinical information about the resident, such as resident risk factors and Braden Score.
  2. The Wound Assessment: Ulcer Information form (Ulcer Information Form) is a four-page form used to document a detailed assessment of a single pressure ulcer. Use a separate Wound Assessment: Ulcer Information form for each pressure ulcer. Since it is not unusual for a single resident to have multiple pressure ulcers, there may be one Resident Information Form to many Ulcer Assessment Forms for a single resident. Both types of forms are to be completed each week until all pressure ulcers are healed.

An ulcer is considered resolved or healed when indicated by the clinician; clinician selects "healed" option as the "Followup Ulcer Status" on the Ulcer Information form. 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, a new Resident Information form and Ulcer Information form are initiated once again as a set.

When either a Resident Information form or Ulcer Information form is completely filled, another set of forms needs to be initiated to continue documentation. It is important to record Resident name, resident ID, and ulcer location at the top of each new set of forms. Providing this information will ensure accurate association of resident and ulcer information from one set of forms to another.

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III. Form-Specific Instructions for Wound Assessment: Resident Information (Form 1)

This form is completed weekly for each resident with a pressure ulcer. Select for Form 1 ( PDF Version [ PDF file - 278.68 KB] ).

Report Date (Assessment Date). A report date must be documented each week the form is completed. The report date should represent the date the ulcer assessment was completed; all information recorded on the form is associated with a report or assessment date. If the report date is missing, any system calculations using dates will display as blank in the report. For example, ulcer days or ulcer duration is computed using report date and Ulcer ID date. Both dates are required for calculation of ulcer days. If either date is missing, "ulcer days" will not display on pressure ulcer reports.

Report Type (Assessment Type). The report type is either "initial" or "followup." The first time Form 1 is completed, select "initial" report type. For each subsequent assessment, select "followup." If a new blank form is initiated as a continuation of previous reporting, select "followup" report.

Risk Factors. There are 25 options listed in the Risk Factors section of the form. Use an X to select all risk factors appropriate for the resident. If "other" is selected, you may document additional details in daily notes or document according to facility procedures. The system will count and store the total number (risk factor sum) of risk factors selected each report week and associate that value with the report date.

Resident risk factors may not change from report week to report week. If "no change in risk factors since last report date" is selected, the system will carry forward the previously checked risk factor elements and associate the elements with the current report date in the system.

Other Clinical Information. Use this section of the form to record resident weight and Braden score and to indicate if resident left the facility since the last report date. Completion of information contained in this section is optional.

  • Resident Weight: If resident weight is being recorded on a digitized CNA form, you do not have to record resident weight on this form unless it is helpful to see weight information display on this form week to week. The system uses the weight recorded on the CNA form for all weight calculations in reports. If your facility does not use the digitized CNA form, weights will be calculated from this field.
  • Resident left facility since last report date: Place an X in the appropriate space (hospital admission or ER visit) if the resident left the facility since the last report date. Use this section of the form if the resident who left the facility is not considered a new admission upon return. The system will associate the date of the report with the hospital admission or ER visit. If a returning resident is treated as a new admission, initiate a new set of forms per facility procedure.
  • Braden Score: It is optional to enter the Braden score that is in effect during the report date. If the Braden tool is not completed weekly, do not transpose the score from week to week, but update the score when a new score becomes available.

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IV. Form-Specific Instructions for Wound Assessment: Ulcer Information (Form 2)

This form is completed weekly for each ulcer being assessed for a single resident. The form contains elements that are to be completed once per ulcer and elements that are to be completed weekly per ulcer. Select for Form 2 ( PDF Version [ PDF file - 1,005.31 KB] ).

Form Information To Complete Once per Ulcer

The form information included in the list below is completed once; all other information contained on the form is completed weekly.

  • Ulcer ID Date.
  • Ulcer Occurrence.
  • Ulcer Condition.
  • Initial Ulcer Stage.
  • Ulcer Location.

Using the ulcer information above, the system will assign a unique identifier (ulcer ID) to each ulcer. All assessments, treatments, and associated resident clinical information, including risk factors, are associated with a unique ulcer ID.

Ulcer ID Date. Place an X in the appropriate month, day, and year space to indicate the date the ulcer was first identified (ulcer onset date).

Occurrence. Select "admission" if the ulcer is present when the resident is admitted to the facility or "acquired" if ulcer developed during resident stay (in-house acquired).

Condition. Indicate if ulcer is a new ulcer or one that is a reopened previously treated ulcer. An ulcer is considered reopened if there is prior history of stage II ulcer or greater in the same location within 2 weeks of closed wound (area=0).

Initial Stage. Indicate the stage of the ulcer when it was first identified: I, II, III, IV, or unstageable.

Ulcer Location. Choose ulcer location from the list of options; indicate right (R) or left (L) where appropriate.

Form Information To Complete Weekly for Each Ulcer

Ulcer Dimensions. Use this section of the form to record ulcer length, width, and depth. The system will calculate the ulcer surface area by multiplying ulcer length x ulcer width and will store a value 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

There are two methods for measuring the ulcer length: clock method (C) and longest aspect of the wound (L). Use the method preferred by your facility. When ulcer length displays on pressure ulcer reports, a (C) or (L) will display.

  • Length:
    • Clock method): Using clock method, enter ulcer length in cm.
    • Longest aspect of the wound): Using longest aspect method, enter ulcer length in cm.
  • Width: Enter longest width of ulcer in cm.
  • Depth: Enter ulcer depth in cm

Drainage/Exudate Type. Select the response that best describes the wound. Use the Bates-Jensen Wound Assessment Tool (© 2001 Barbara Bates-Jensen) for additional information and general guidelines.

Drainage/Exudate Amount. Select the response that best describes the wound. Use the Bates-Jensen Wound Assessment Tool (© 2001 Barbara Bates-Jensen) for additional information and general guidelines.

Wound Edges. Select the response that best describes the wound. Use the Bates-Jensen Wound Assessment Tool (© 2001 Barbara Bates-Jensen) for additional information and general guidelines.

Peri Wound Area. Select the response that best describes the wound. Use the Bates-Jensen Wound Assessment Tool (© 2001 Barbara Bates-Jensen) for additional information and general guidelines.

Peripheral Tissue Edema. Select the response that best describes the wound. Use the Bates-Jensen Wound Assessment Tool (© 2001 Barbara Bates-Jensen) for additional information and general guidelines.

Peripheral Tissue Induration. Select the response that best describes the wound. Use the Bates-Jensen Wound Assessment Tool (© 2001 Barbara Bates-Jensen) for additional information and general guidelines.

Granulation. Select the response that best describes the wound. Use the Bates-Jensen Wound Assessment Tool (© 2001 Barbara Bates-Jensen) for additional information and general guidelines.

Epithelialization. Select the response that best describes the wound. Use the Bates-Jensen Wound Assessment Tool (© 2001 Barbara Bates-Jensen) for additional information and general guidelines.

Necrotic Tissue Type. Select the response that best describes the wound. Use the Bates-Jensen Wound Assessment Tool (© 2001 Barbara Bates-Jensen) for additional information and general guidelines.

Necrotic Tissue Amount. Select the response that best describes the wound. Use the Bates-Jensen Wound Assessment Tool (© 2001 Barbara Bates-Jensen) for additional information and general guidelines.

Tunneling. Select the response that best describes the wound. Note that this element is not included on the Bates-Jensen Wound Assessment Tool.

  • Tunneling Direction: Select the value (clock direction) that best describes tunneling direction.
  • Tunneling Length: Enter the tunneling length in cm.

Undermining. Select the response that best describes the wound. Two options are provided to record undermining assessment: direction and length or values 1-5. Use the method preferred by your facility.

  • Undermining Direction: Select the value (clock direction) that best describes undermining direction.
  • Undermining Length: Enter the undermining length in cm.
  • Undermining 1-5: Use the Bates-Jensen Wound Assessment Tool (© 2001 Barbara Bates-Jensen) for additional information and general guidelines.

Pain. Use this section to indicate resident level of pain, if any, and if pain medication is given.

  • Is the ulcer site painful? Using a pain scale 0-10, enter a number 0-10 in the space provided; 0 = no pain and 10 = worst pain.
  • Pain medication given for ulcer pain? Place an X in the space provided to indicate pain medication given; leave blank if no medication given for pain.

Treatments. Choose all ulcer treatments that are in effect at the time of the report. The system will associate all selected treatments with the report date and the ulcer ID.

Documentation Rules:

  • If treatments have not changed since previous report week, select "no change in treatments since last report date." If this option is selected, the system will carry forward the previously checked treatments and associate those elements with the current report date.
  • If treatments have changed (new treatments added or previous treatments stopped) since the previous report week, you must select all treatments in effect at the time of the report, including any treatments that were selected during the most recent report. If a treatment element previously selected is not carried forward or rechecked during the current report week, the system will assign a stop date to the treatment; report date becomes the stop date.

Adjunctive Therapies. Adjunctive therapies section is a continuation of ulcer treatments. Please choose all adjunctive therapies that are in effect at the time of the report. The system will associate all selected therapies with the report date. Use documentation rules described in "Treatments" (see above).

Interventions. Choose all ulcer interventions that are in effect at the time of the report. Use documentation rules described in "Treatments" (see above).

Consultation. Choose all wound consultations that were requested during the report week. If "other" is selected, you may document additional details in daily notes or document according to facility procedures.

Followup Ulcer Status. Use this section to record subjective impression of ulcer status at the time of the report or assessment: healed, improving, unchanged, or worsening. Ulcer status displays on pressure ulcer reports, e.g., worsening ulcers display on stagnant ulcer report, healed ulcer will display on healed ulcer report.

Definition of "healed" is that the ulcer is closed or area is 0. When "healed" is selected, the system stores "ulcer heal date" using the report date.

Current Visualized Stage. Record the ulcer stage, as visualized at the time of the report or assessment. We acknowledge NPUAP and WOCN recommendations not to downstage pressure ulcers. To comply with Medicare and Medicaid documentation requirements, however, pressure ulcers will be staged as visualized at the time of each report or assessment. You may leave this blank if this is the facility preference.

Resident Disposition. If the resident has left the facility since the most recent report date, choose appropriate disposition: resident discharged since last report date, or resident expired since last report date.

Comments. Use the comments section of the form for additional notes and documentation. The digital pen does not capture or store free-text, handwritten notes for reporting, but the information will be available on the stored image.

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Page last reviewed July 2009
Internet Citation: Instructions To Complete Wound Assessment Forms: 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/waforminst.html