Form 1

Wound Assessment: Resident Risk Factors

Patient ID:

Facility Name  _______________________________________

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

Resident ID: _____________________________________

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

Current as of July 2009

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Internet Citation:

On-Time Pressure Ulcer Healing Project: Form 1: Wound Assessment: Resident Risk Factors. July 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/pressureulcerhealing/waform1.htm

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