prevention plan Check the care plan, the eMR, progress notes for the person? or clinical notes for this information. 22772 Compliance Q10. Is there Yes Check the patient’s records for the last three days. documentation in No Select No if there is no skin assessment and risk the healthcare N/A assessment documented for each 24 hour record of fully period. completed If the initial risk assessment is within the last comprehensive three days then consider if there is documented risk reassessment reassessment of the person’s risk on each day. E.g. Patient has been on the ward for two days (using a validated and both the initial and daily assessment have tool and been completed select Yes. comprehensive Select N/A if the patient is not currently skin assessment) identified as ‘at risk’ of pressure injury. on each of the last 3 days? 10385 Compliance Q11. Is there Yes Yes can only be selected if documented in the clinical record/care plan that information has documentation of No been provided. information on the prevention of pressure injury being provided to the person or their carer? 22773 Single Q12. Is a pressure Yes Check the care plan, the eMR, progress notes Choice injury or injuries or clinical notes for this information. No documented within the last three days? 21168 Single Q13. Is there Urinary incontinence Check the care plan, the eMR, progress notes Choice documentation of or clinical notes for this information. Faecal incontinence the person being Both faecal and urinary incontinence incontinent? Catheterised with leakage Catheterised without leakage
prevention plan for the person? Check the care plan, the eMR, progress notes or clinical notes for this information. 22772 Compliance Q10. Is there documentation in the healthcare record of fully completed comprehensive risk reassessment (using a validated tool and comprehensive skin assessment) on each of the last 3 days? Yes No N/A Check the patient’s records for the last three days. Select No if there is no skin assessment and risk assessment documented for each 24 hour period. If the initial risk assessment is within the last three days then consider if there is documented reassessment of the person’s risk on each day. E.g. Patient has been on the ward for two days and both the initial and daily assessment have been completed select Yes. Select N/A if the patient is not currently identified as ‘at risk’ of pressure injury. 10385 Compliance Q11. Is there documentation of information on the prevention of pressure injury being provided to the person or their carer? Yes No Yes can only be selected if documented in the clinical record/care plan that information has been provided. 22773 Single Choice Q12. Is a pressure injury or injuries documented within the last three days? Yes No Check the care plan, the eMR, progress notes or clinical notes for this information. 21168 Single Choice Q13. Is there documentation of the person being incontinent? Urinary incontinence Faecal incontinence Both faecal and urinary incontinence Catheterised with leakage Catheterised without leakage Check the care plan, the eMR, progress notes or clinical notes for this information.
Pressure-Injury-Point-Prevalence-Survey-Guide-2018.docx