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 or notes or clinical notes. 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 occurred. Select N/A only when it is less than 8 hours since the person’s arrival on the unit. 10885 Compliance Q9. Is there Yes can only be selected if pressure injury Yes documentation of prevention plan is present in the medical No an appropriate record. pressure injury Check the care plan, the eMR, progress notes prevention plan or clinical notes for this information. for the person? 22984 Compliance Q10. Is there Check the patient’s records for the last month. Yes documentation in Select No if there is no skin assessment and No the healthcare risk assessment documented for each week. N/A record of fully If the initial risk assessment is within the last completed week then answer Yes. comprehensive Select N/A if the patient is not currently risk reassessment identified as ‘at risk’ of pressure injury. (using a validated tool and comprehensive
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 occurred. Select N/A only when it is less than 8 hours since the person’s arrival on the 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 present in the medical record. Check the care plan, the eMR, progress notes or clinical notes for this information. 22984 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 month. Select No if there is no skin assessment and risk assessment documented for each week. If the initial risk assessment is within the last week then answer Yes. Select N/A if the patient is not currently identified as ‘at risk’ of pressure injury.
Pressure-Injury-Point-Prevalence-Survey-Guide-Updated-October-2017.docx