Skin Assessment on Admission Audit

Audit template for verifying complete admission skin assessments, including Braden score documentation, head-to-toe skin inspection, device-related skin checks, and photo evidence where required.

Admission Assessment Documentation

• Admission skin assessment completed within required timeframe
  Confirm the skin assessment was completed on admission per facility policy and documented in the chart.
• Assessment includes complete skin integrity documentation
  Check that the record documents intact skin, existing wounds, redness, bruising, tears, moisture-associated damage, and other abnormalities.
• Assessment location and assessor are documented
  Verify the note identifies who completed the assessment and where it was performed.
• Relevant history or risk factors documented
  Check whether prior pressure injuries, mobility limitations, incontinence, nutrition concerns, or other risk factors are documented.
• Follow-up actions initiated for identified concerns
  Verify that any abnormal findings triggered appropriate follow-up, escalation, or care plan updates.

Braden Score Assessment

• Braden score documented
  Verify a Braden score is recorded in the admission assessment.
• Braden subscales documented
  Confirm the six Braden subscales are documented or otherwise available for review.
• Risk level aligns with Braden score
  Verify the documented risk category matches the numeric score and facility thresholds.
• Preventive interventions initiated based on risk
  Check whether pressure injury prevention measures were started when indicated by the risk score.

Head-to-Toe Skin Inspection

• Head-to-toe skin inspection completed
  Confirm the assessment covers the full body surface, not only high-risk areas.
• Skin findings documented by body area
  Verify findings are recorded by anatomical location with clear descriptors.
• Pressure injuries, wounds, or tears described clearly
  Check that any open areas or suspected pressure injuries are described with enough detail for clinical follow-up.
• Skin over bony prominences assessed
  Verify high-risk areas such as sacrum, heels, elbows, hips, and occiput were specifically checked.
• Moisture, incontinence, or dermatitis concerns documented
  Confirm moisture-associated skin damage or related concerns are identified when present.

Device-Related Skin Check

• All medical devices present on admission identified
  Verify devices such as oxygen tubing, splints, catheters, braces, or monitoring equipment are listed if present.
• Skin under and around devices inspected
  Check that the chart documents inspection of device contact points and adjacent skin.
• Device-related pressure or friction injury documented when present
  Verify any device-related skin injury is clearly documented and differentiated from other wounds.
• Device repositioning or padding interventions documented
  Confirm protective interventions were documented when device pressure risk was identified.

Photo Documentation and Follow-Up

• Photo evidence obtained for wounds or areas requiring documentation
  Confirm photos were taken when required by policy or when clinically indicated for wounds or skin breakdown.
• Photo consent or policy compliance documented
  Check that photo capture followed consent and facility policy requirements.
• Escalation and follow-up documented for abnormal findings
  Confirm abnormal findings were escalated to the appropriate clinician and follow-up actions were initiated.