Pressure Ulcer Risk Assessment
Systematic evaluation of patient risk for pressure ulcer development. Please complete all sections accurately.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient ID or Hospital Number
*
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor Name and Role
*
Risk Factor Assessment Table
*
Rows
Score 1
Score 2
Score 3
Score 4
Sensory Perception
1
2
3
4
Moisture
5
6
7
8
Activity
9
10
11
12
Mobility
13
14
15
16
Nutrition
17
18
19
20
Friction and Shear
21
22
23
24
Total Risk Score (sum of above)
*
Skin Condition Observed
*
Intact
Redness/Non-blanchable Erythema
Blister/Partial Thickness Loss
Full Thickness Loss/Ulcer
Other (specify)
Current Interventions in Place
Regular repositioning
Pressure-relieving mattress/cushion
Moisture management
Nutritional support
Skin protection/barrier creams
Other (specify)
Comments or Additional Observations
Assessor Signature
*
Submit Assessment
Submit Assessment
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