Pressure Injury Documentation Survey
Document key details of a pressure injury case using this streamlined survey.
Date of Documentation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pressure Injury Location
*
Please Select
Sacrum
Heel
Ischium
Trochanter
Occiput
Other
Pressure Injury Stage
*
Stage 1
Stage 2
Stage 3
Stage 4
Unstageable
Deep Tissue Injury
Estimated Size (cm)
Tissue Type Observed
Intact skin
Slough
Eschar
Granulation tissue
Epithelial tissue
Other
Exudate Amount
None
Scant
Moderate
Heavy
Periwound Skin Condition
Normal
Redness
Maceration
Induration
Other
Pain Level (0 = No Pain, 10 = Worst Pain)
0
0
1
2
3
4
5
6
7
8
9
10
10
0 is 0, 10 is 10
Interventions Initiated
Pressure relief
Moisture management
Wound dressing applied
Nutrition consult
Other
Additional Notes (if any)
Submit Survey
Should be Empty: