Resident ID: REPORT DATE M M D D Y Y M M D D Y Y M M D D Y Y M M D D Y Y M M D D Y Y M M D D Y Y Granulation 1= Skin intact or partial thickness wound 2= Bright, beefy red; 75% - 100% of wound filled and/or tissue overgrowth- 3= Bright, beefy red; < 75% and > 25% of wound filled 4= Pink and/or dull dusky red and/or fills ≤25% of wound 5= No granulation tissue present Enter Granulated Amt (enter % if 1-5 above not used at your facility) Epithelialization 1= 100% wound covered, surface intact 2= 75% to <100% wound covered and/or epithelial tissue extends >0.5 cm into wound bed 3= 50% to <75% wound covered and/or epithelial tissue extends to <0.5 cm into wound bed 4= 25% to <50% wound covered 5= <25% wound covered Pain 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 Pressure Ulcer Site Pain 3 4 5 3 4 5 3 4 5 3 4 5 3 4 5 3 4 5 6 7 8 6 7 8 6 7 8 6 7 8 6 7 8 6 7 8 Select 0-10 on pain scale 9 10 9 10 9 10 9 10 9 10 9 10 Pain medication given for ulcer pain Current Pressure Ulcer Stage Stage 1 Stage 2 Stage 3 Stage 4 Unstageable Suspected Deep Tissue Injury (sDTI) Followup Ulcer Status Per Nurse Assessment Healed Improving No change Worsening Comments Resident ID:
Resident ID: REPORT DATE M M D D Y Y M M D D Y Y M M D D Y Y M M D D Y Y M M D D Y Y M M D D Y Y Granulation 1= Skin intact or partial thickness wound 2= Bright, beefy red; 75% - 100% of wound filled and/or tissue overgrowth- 3= Bright, beefy red; < 75% and > 25% of wound filled 4= Pink and/or dull dusky red and/or fills ≤25% of wound 5= No granulation tissue present Enter Granulated Amt (enter % if 1-5 above not used at your facility) Epithelialization 1= 100% wound covered, surface intact 2= 75% to <100% wound covered and/or epithelial tissue extends >0.5 cm into wound bed 3= 50% to <75% wound covered and/or epithelial tissue extends to <0.5 cm into wound bed 4= 25% to <50% wound covered 5= <25% wound covered Pain Pressure Ulcer Site Pain Select 0-10 on pain scale 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 Pain medication given for ulcer pain Current Pressure Ulcer Stage Stage 1 Stage 2 Stage 3 Stage 4 Unstageable Suspected Deep Tissue Injury (sDTI) Followup Ulcer Status Per Nurse Assessment Healed Improving No change Worsening Comments Resident ID:
puh-assessment.docx