22771 Compliance Q8. Is there Check the eMR, progress Notes, clinical Notes Yes documentation of for this information. No a fully completed The time of admission to the unit/service N/A comprehensive should be available from the eMR, progress risk assessment notes or clinical notes. or reassessment Select Yes when the receiving ward has (using a validated documented that a validated pressure injury tool and risk assessment tool/ process appropriate for comprehensive the patient population in accordance with best skin assessment) practice guidelines has been completed, AND a on transfer to this skin assessment that is based on visual ward? inspection has been documented. Select N/A only when it is less than 8 hours since the patient’s arrival on the ward/unit. 10885 Compliance Q9. Is there Yes can only be selected if pressure injury Yes documentation of prevention plan is documented in the medical No an appropriate record or care plan. pressure injury Check the care plan, the eMR, progress notes prevention plan or clinical notes for this information. for the person? 22772 Compliance Q10. Is there Check the patient’s records for the last three Yes documentation in days. No the healthcare Select No if there is no skin assessment and risk N/A record of fully assessment documented for each 24 hour completed period. comprehensive If the initial risk assessment is within the last risk reassessment three days then consider if there is documented (using a validated reassessment of the person’s risk on each day. tool and E.g. Patient has been on the ward for two days comprehensive and both the initial and daily assessment have
22771 Compliance Q8. Is there documentation of a fully completed comprehensive risk assessment or reassessment (using a validated tool and comprehensive skin assessment) on transfer to this ward? Yes No N/A Check the eMR, progress Notes, clinical Notes for this information. The time of admission to the unit/service should be available from the eMR, progress notes or clinical notes. Select Yes when the receiving ward has documented that a validated pressure injury risk assessment tool/ process appropriate for the patient population in accordance with best practice guidelines has been completed, AND a skin assessment that is based on visual inspection has been documented. Select N/A only when it is less than 8 hours since the patient’s arrival on the ward/unit. 10885 Compliance Q9. Is there documentation of an appropriate pressure injury prevention plan for the person? Yes No Yes can only be selected if pressure injury prevention plan is documented in the medical record or care plan. 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 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
Pressure-Injury-Point-Prevalence-Survey-Guide-Updated-October-2017.docx