CNA Skin Assessment Checklist Form
Complete this checklist to document key observations during a CNA skin assessment. Please answer all sections accurately.
Resident/Patient Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Areas Checked
*
Heels
Sacrum/Coccyx
Elbows
Shoulders
Back
Other
Skin Condition Observed
Rows
Intact
Redness
Bruising
Open Area
Moisture
Heels
1
2
3
4
5
Sacrum/Coccyx
6
7
8
9
10
Elbows
11
12
13
14
15
Shoulders
16
17
18
19
20
Back
21
22
23
24
25
Are there any signs of pressure injury?
*
No
Yes
If yes, describe location and appearance
Skin Temperature (to touch)
Warm
Cool
Normal
Moisture Level
Dry
Moist
Excessively Moist
Risk Factors Present
Immobility
Incontinence
Poor Nutrition
Diabetes
Other
Additional Comments or Observations
Submit Assessment
Should be Empty: