COMMUNITY/OUTPATIENT SURVEY Questionnaire CEC_08_PI_Prevalence_Community_Outpatient_2017_Revised (3495) Patient Oriented No Questionnaire Instruction Base survey to conduct the 2017 pressure injury prevalence survey for inpatients. Local Health Districts or Health Networks should copy this survey and customise as required for local needs. A guide for customising and delivering the survey is available from the Project Officer, CEC Pressure Injury Prevention Project Creator Group New South Wales ( Pressure Injury ) Question Question Question Responses Instructions ID # type 10375 Single Q1. What sex is Record the patient’s sex from the medical Female Choice the person? record. Male Other should be selected when it is Other documented in the medical record that the patient identifies as intersex. 21167 Number Q2. What is the __Years If the person is less than 1 year old please with one age of the provide their age using a decimal value. i.e. 6 decimal person? months is 0.5 Years point 22976 Compliance Q3. Is there Select Yes when there is documentation that a Yes documentation of validated pressure injury risk assessment tool/ No a fully completed process appropriate for the patient population comprehensive in accordance with best practice guidelines, If Yes, jump to question no: 5; risk assessment AND a skin assessment that is based on visual (using a validated inspection has occurred. tool and Check the eMR, progress notes, clinical notes comprehensive or other nursing discharge summary’s for this skin assessment) information. at first The time of admission should be available from
COMMUNITY/OUTPATIENT SURVEY Questionnaire CEC_08_PI_Prevalence_Community_Outpatient_2017_Revised (3495) Patient Oriented No Questionnaire Instruction Base survey to conduct the 2017 pressure injury prevalence survey for inpatients. Local Health Districts or Health Networks should copy this survey and customise as required for local needs. A guide for customising and delivering the survey is available from the Project Officer, CEC Pressure Injury Prevention Project Creator Group New South Wales ( Pressure Injury ) Question ID # Question type Question Responses Instructions 10375 Single Choice Q1. What sex is the person? Female Male Other Record the patient’s sex from the medical record. Other should be selected when it is documented in the medical record that the patient identifies as intersex. 21167 Number with one decimal point Q2. What is the age of the person? __Years If the person is less than 1 year old please provide their age using a decimal value. i.e. 6 months is 0.5 Years 22976 Compliance Q3. Is there documentation of a fully completed comprehensive risk assessment (using a validated tool and comprehensive skin assessment) at first Yes No If Yes, jump to question no: 5; Select Yes when there is documentation that a validated pressure injury risk assessment tool/ process appropriate for the patient population in accordance with best practice guidelines, AND a skin assessment that is based on visual inspection has occurred. Check the eMR, progress notes, clinical notes or other nursing discharge summary’s for this information. The time of admission should be available from
Pressure-Injury-Point-Prevalence-Survey-Guide-Updated-October-2017.docx