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Admission Assessment Documentation

Admission skin assessment completed within required timeframe critical (required)

Confirm the skin assessment was completed on admission per facility policy and documented in the chart.

Yes No N/A

Assessment includes complete skin integrity documentation critical (required)

Check that the record documents intact skin, existing wounds, redness, bruising, tears, moisture-associated damage, and other abnormalities.

Yes No N/A

Assessment location and assessor are documented

Verify the note identifies who completed the assessment and where it was performed.

Yes No N/A

Relevant history or risk factors documented

Check whether prior pressure injuries, mobility limitations, incontinence, nutrition concerns, or other risk factors are documented.

Yes No N/A

Follow-up actions initiated for identified concerns

Verify that any abnormal findings triggered appropriate follow-up, escalation, or care plan updates.

Yes No N/A

Braden Score Assessment

Braden score documented critical (required)

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.

Yes No N/A

Risk level aligns with Braden score critical (required)

Verify the documented risk category matches the numeric score and facility thresholds.

Yes No N/A

Preventive interventions initiated based on risk

Check whether pressure injury prevention measures were started when indicated by the risk score.

Yes No N/A

Head-to-Toe Skin Inspection

Head-to-toe skin inspection completed critical (required)

Confirm the assessment covers the full body surface, not only high-risk areas.

Yes No N/A

Skin findings documented by body area

Verify findings are recorded by anatomical location with clear descriptors.

Yes No N/A

Pressure injuries, wounds, or tears described clearly critical (required)

Check that any open areas or suspected pressure injuries are described with enough detail for clinical follow-up.

Yes No N/A

Skin over bony prominences assessed

Verify high-risk areas such as sacrum, heels, elbows, hips, and occiput were specifically checked.

Yes No N/A

Moisture, incontinence, or dermatitis concerns documented

Confirm moisture-associated skin damage or related concerns are identified when present.

Yes No N/A

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.

Yes No N/A

Skin under and around devices inspected critical (required)

Check that the chart documents inspection of device contact points and adjacent skin.

Yes No N/A

Device-related pressure or friction injury documented when present

Verify any device-related skin injury is clearly documented and differentiated from other wounds.

Yes No N/A

Device repositioning or padding interventions documented

Confirm protective interventions were documented when device pressure risk was identified.

Yes No N/A

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.

Yes No N/A

Photo evidence (optional)

Photo consent or policy compliance documented

Check that photo capture followed consent and facility policy requirements.

Yes No N/A

Escalation and follow-up documented for abnormal findings critical (required)

Confirm abnormal findings were escalated to the appropriate clinician and follow-up actions were initiated.

Yes No N/A

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Run: Skin Assessment on Admission Audit

Admission Assessment Documentation

Braden Score Assessment

Head-to-Toe Skin Inspection

Device-Related Skin Check

Photo Documentation and Follow-Up

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