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 been documented. Select N/A only when it is less than 8 hours since the patient’s arrival on the ward/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 documented in the medical record or care plan. Check the care plan, the eMR, progress notes or clinical notes for this information. 22772 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 three days. Select No if there is no skin assessment and risk assessment documented for each 24 hour period. If the initial risk assessment is within the last three days then consider if there is documented reassessment of the person’s risk on each day. E.g. Patient has been on the ward for two days and both the initial and daily assessment have
skin assessment) within 8 hours of presentation to your facility? information. The time of admission should be available from the eMR, admission summary sheet or similar. 21351 Single Choice Q5 Is there documentation of the person receiving one element of the comprehensive risk assessment? A fully completed comprehensive skin assessment within 8 hours of presentation to your facility A fully completed risk assessment using a validated tool within 8 hours of presentation to your facility The person received neither of the above if The person received neither of the above, jump to question no: 8 Select The person received neither of the above when neither a fully completed validated pressure injury risk assessment tool has been completed NOR a fully completed skin assessment that is based on visual inspection has been documented. If one or the other has been completed select the appropriate answer. 22697 Single Choice Q6. At the initial risk assessment (within 8 hours of presentation to the facility) was the person? Not at risk of pressure injury At risk of pressure injury An initial risk assessment is not documented for this person if Not at risk of pressure injury, jump to question no: 12; if An initial risk assessment is not documented for this person, jump to question no: 8 If the person received a comprehensive risk assessment within 8 hours of presentation select Not at risk or at no risk of pressure injury or At risk of pressure injury. If the person did not receive an initial risk assessment within 8 hours of presentation to the facility choose An initial risk assessment is not documented for this person. 11540 Matrix Q7. At the initial risk assessment (within 8 hours of presentation to the organisation) which tool was used and what was the risk category? See table below. Select one of the risk category answer options for the risk assessment tool used during the initial risk assessment. Indicate the risk assessment tool used and the person’s level of risk identified using that tool. Check the eMR, progress Notes, clinical notes for this information.
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.
skin assessment) weekly for the last 3 weeks? 10385 Compliance Q11. Is there documentation of information on the prevention of pressure injury being provided to the person or their carer? Yes No Yes can only be selected if documented in the clinical record/care plan that information has been provided. 22985 Single Choice Q12. Is a pressure injury or injuries documented within the last week? Yes No Check the care plan, the eMR, progress notes or clinical notes for this information. 21168 Single Choice Q13. Is there documentation of the person being incontinent? Urinary incontinence Faecal incontinence Both faecal and urinary incontinence Catheterised with leakage Catheterised without leakage The patient is continent If Catheterised without leakage, jump to question no: 15; if The patient is continent, jump to question no: 15 Check the care plan, the eMR, progress notes or clinical notes for this information. 22698 Single Choice Q14. Is there documentation the person has Incontinence Associated Dermatitis (IAD)? Yes No Check the care plan, the eMR, progress notes or clinical notes for this information. 11996 Single Choice Q15. Was a comprehensive Yes The survey team must gain verbal consent from the person or their family or carer prior
skin inspection conducted by the survey team, on the day of the audit? No If No, jump to question no: 22 to attending the skin inspection. It is important to ensure that the patient is fully informed, understands the rationale for care, and consents to this occurring. 22112 Single Choice Q16. On conducting a skin inspection on the day of the audit. Does the person have a pressure injury or IAD? Yes No If No, jump to question no: 22 This question is based on visual skin inspection. Answer Yes if the person has either or both PI and IAD. 22699 Matrix Q17. What was the classification of the pressure injury or injuries or the IAD? See table below. Record up to the four most severe injuries. Select one of the PI or IAD classification/category answer options for up to four of the person’s most severe injuries. WHERE a person has more than four injuries document this information in the comments section of this question PI or IAD E, PI or IAD F, PI or IAD G etc. 22700 Matrix Q18. What was the location of the pressure injury or injuries or the IAD? See table below. Record up to the four most severe injuries Select one of the location options for up to four of the person’s most severe injuries WHERE a person has more than four injuries document this information in the comments section of this question PI or IAD E, PI or IAD F, PI or IAD G etc.
COMMUNITY/OUTPATIENT SURVEY Questionnaire CEC_08_PI_Prevalence_Community_Outpatient_2017_Revised (3495) Patient Oriented No Questionnaire Instruction Base survey to conduct the 2017 pressure injury prevalence survey for inpatients. Local Health Districts or Health Networks should copy this survey and customise as required for local needs. A guide for customising and delivering the survey is available from the Project Officer, CEC Pressure Injury Prevention Project Creator Group New South Wales ( Pressure Injury ) Question ID # Question type Question Responses Instructions 10375 Single Choice Q1. What sex is the person? Female Male Other Record the patient’s sex from the medical record. Other should be selected when it is documented in the medical record that the patient identifies as intersex. 21167 Number with one decimal point Q2. What is the age of the person? __Years If the person is less than 1 year old please provide their age using a decimal value. i.e. 6 months is 0.5 Years 22976 Compliance Q3. Is there documentation of a fully completed comprehensive risk assessment (using a validated tool and comprehensive skin assessment) at first Yes No If Yes, jump to question no: 5; Select Yes when there is documentation that a validated pressure injury risk assessment tool/ process appropriate for the patient population in accordance with best practice guidelines, AND a skin assessment that is based on visual inspection has occurred. Check the eMR, progress notes, clinical notes or other nursing discharge summary’s for this information. The time of admission should be available from
10885 Compliance Q7. 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. 22982 Compliance Q8. Is there documentation in the healthcare record of fully completed comprehensive risk reassessment (using a validated tool and comprehensive skin assessment) within the last month? 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 in that month. If the initial risk assessment is within the last month answer Yes. Select N/A if the patient is not currently identified as ‘at risk’ of pressure injury. 10385 Compliance Q9. Is there documentation of information on the prevention of pressure injury being provided to the person or their carer? Yes No Yes can only be selected if documented in the clinical record/care plan that information has been provided.