Pressure Ulcer Check Form
Complete this form to document and assess pressure ulcers in a healthcare setting.
Patient Identifier (e.g., Medical Record Number or Initials)
*
Assessment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Ulcer Location
*
Please Select
Sacrum
Heel
Hip
Ischium
Elbow
Other
Ulcer Stage/Severity
*
Stage 1: Non-blanchable erythema
Stage 2: Partial-thickness skin loss
Stage 3: Full-thickness skin loss
Stage 4: Full-thickness tissue loss
Unstageable
Deep tissue injury
Wound Characteristics (describe size, appearance, exudate, odor)
*
Risk Factors Present
Reduced mobility
Poor nutrition
Moisture exposure
Impaired sensation
Other
Current Care or Treatment Provided
Pain Assessment (0 = No pain, 10 = Worst pain)
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Follow-up Actions/Next Steps
Submit Assessment
Should be Empty: