Self-Assessment Worksheet for Pressure Ulcer Healing

AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing

This self-assessment tool is an important first step in implementing the On-Time electronic reports into current workflow to help inform pressure ulcer wound interventions and improve healing rates. The worksheet will help you understand current practices and identify gaps in identifying risk, communicating risk, and receiving input from a multidisciplinary team. This assessment should show how well the nursing home:

  • Identifies pressure ulcer nonhealing risk factors using information from multiple sources.
  • Develops interventions specific to the risk factors to mitigate risk.
  • Communicates the intervention to all staff using multiple processes.

This assessment will cover the following:

Section 1: Pressure Ulcer Tracking and Assessment      

  1. What tools, if any, do you use to monitor pressure ulcer healing? Check all that apply.
  Individual Patient/
Resident Level
Facility Level
Advancing Excellence Pressure Ulcer Tracking Tool    
Facility-developed forms/database    
Corporate-directed forms/database    
Paper records/log    
PUSH Pressure Ulcer Healing Tool    
BWAT – Bates-Jenson Wound Assessment Tool    
None of the above    
Other (specify)    
  1. How often do you reassess pressure ulcers?
    1. ___ Daily
    2. ___ Weekly
    3. ___ Monthly
    4. ___ Other (specify): _____________________________________________________
  2. Do you collect the following information?
    Unit Level
a. Total count of ulcers ___ Yes   ____ No ___ Yes   ____ No
b. Count of ulcers by stage ___ Yes   ____ No ___ Yes   ____ No
  1. How often is the information updated?
    1. Total count of pressure ulcers is updated:
      ___ Daily
      ___ Weekly
      ___ Every 2 weeks
      ___ Monthly
      ___ Quarterly
    2. Total count of pressure ulcers by stage is updated:
      ___ Daily
      ___ Weekly
      ___ Every 2 weeks
      ___ Monthly
      ___ Quarterly
  2. Does your assessment of pressure ulcers include the following items:
  Yes No
Ulcer site ___ ___
Current stage ___ ___
Surface area ___ ___
Length ___ ___
Width ___ ___
Depth ___ ___
Onset date ___ ___
Ulcer days ___ ___
Initial stage ___ ___
Initial origin (in-house or present on admission) ___ ___
Undermining/tunneling ___ ___
Wound bed (tissue) ___ ___
Drainage/exudate ___ ___
Periwound tissue (color, temp, bogginess, and fluctuation) ___ ___
Need for debridement ___ ___
Presence of odor ___ ___
Pain (if present, nature and frequency) ___ ___
Other (specify): ___________________________________ ___ ___
Other (specify): ___________________________________ ___ ___

Section 2: Pressure Ulcer Healing Practices

  1. Do you have a protocol for monitoring the progress of pressure ulcer healing?
     Yes ___ No ___ If no, explain: ________________________________________________________________
  2. What guidelines are used in your facility protocol regarding evaluating pressure ulcer healing? Check all that apply. If none, skip to Section 3.
    ___ AMDA – The Society for Post-Acute and Long-Term Care Medicine’s Pressure Ulcer Guidelines
    ___ National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance’s Prevention and Treatment of Pressure Ulcers Guidelines
    ___ Wound, Ostomy, and Continence Nurses Society (WOCN) Pressure Ulcer Guidelines
    ___ Other (specify): __________________________
    ___ None of the above
  3. Does your facility’s protocol include criteria for identifying residents whose pressure ulcers may not heal in a reasonable timeframe due to resident comorbidities and/or wound characteristics (i.e., identification of residents who are at risk for delayed healing before delayed healing is evident)?
    Yes ___ No ___
  4. Does your facility’s protocol include criteria for identifying ulcers that are not healing in an expected timeframe? Yes ___ No ___
    If yes, what are the criteria?
    ____________________________________________________________________________________________

    ____________________________________________________________________________________________

  5. Does your facility protocol provide guidance on:
  Yes No Comments
How to identify potential pressure ulcer infection? ___ ___  
Pressure ulcer debridement? ___ ___  
Selection of dressings based on wound characteristics? ___ ___  
Use of nutritional supplements for residents with pressure ulcers? ___ ___  
Use of support surfaces for bed and chairs/wheelchairs? ___ ___  
Wound cleansing? ___ ___  
Assessing the resident for pain? ___ ___  
Appropriate use of topical wound agents? ___ ___  
Appropriate use of adjunctive treatments? ___ ___  

Section 3: Investigations/Root Cause Analysis of Delayed Pressure Ulcer Healing

  1. Do you investigate delayed healing pressure ulcers according to your facility’s policies and guidelines?
    Yes ___ No ___ Not Sure ___
  2. Do you investigate delayed pressure ulcer healing via a root cause analysis framework?
    Yes ___ No ___ Not Sure ___ If no, skip to Section 4.
  3. Does your investigation include a review of changes to the resident’s clinical status that may have warranted a change in pressure ulcer care approaches?
    Yes ___ No ___ If no, skip to Question 5.
  4. Which of the following changes to the resident’s clinical status would be considered when determining if a change in pressure ulcer care approaches is needed?  Check all that apply.
    ___ Change in condition
    ___ Weight loss
    ___ Change in meal intake
    ___ Change in fluid intake
    ___ Change in mobility
    ___ Change in continence
    ___ Change in ability to communicate pain
  5. Which of the following changes to the resident’s clinical status would be considered when determining if a change in pressure ulcer care approaches is needed?  Check all that apply.
    ___ Nutritional interventions to meet the resident’s hydration, protein, calorie, vitamin, and mineral needs
    ___ Incontinence prevention and/or management
    ___ Management of medical device-related pressure
    ___ Pressure redistribution (e.g., support surfaces) and offloading (e.g., specialized footware)
    ___ Friction and sheer reduction
    ___ Turning and repositioning procedures
    ___ Treatment changes per frequency designated by protocol or provider
    ___ Indicators for debridement
    ___ Assessment for appropriate bed and chair support surfaces
    ___ Skin assessments per frequency designated by protocol or provider
    ___ Dressing protocols
    ___ Infection prevention and assessment
    ___ Other (specify):

Section 4: Communication Practices

  1. Review the following list of meetings. For every meeting that occurs at your facility, indicate how often it occurs, who leads the meeting, and who attends. Also indicate if the meeting includes any discussion of pressure ulcer healing
Meeting Meeting Chair/Leader Name and Discipline Staff Invited and in Attendance (indicate A – Always, V- Varies, as needed) Frequency of Meeting (Weekly, Biweekly, Monthly, Quarterly, Change in Condition, As Needed) Is Pressure Ulcer Healing Discussed? (Y = yes, N = No)
Care plan meeting        
Shift report or "brief" with CNAs        
Report or brief with Department Heads        
Medical staff/medical director meeting        
QAPI or quality improvement review        
Skin rounds or wound  review meeting        
MD/APRN rounds        
Report or brief with Dietary Department        
Report or brief with Social Services Department        
Report or brief with Rehab Department        
Report or brief with “Other”        
Other        

Key: CNA = certified nursing assistant; QAPI = Quality Assessment and Performance Improvement; APRN = advanced practice registered nurse.

  1. Training.

Indicate the date of the most recent training provided for the following:

Topic Participants Date
Measuring pressure ulcers accurately Nurses  
Recognizing signs of delayed healing in pressure ulcers Nurses  
Pressure ulcer assessment documentation Nurses  

Return to On-Time Pressure Ulcer Healing Page

Page last reviewed December 2016
Page originally created March 2013
Internet Citation: Self-Assessment Worksheet for Pressure Ulcer Healing. Content last reviewed December 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/pruhealing/saworksheet.html