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Admission Assessment Documentation

Skin assessment completed within required admission timeframe critical (required)

Verify the assessment was completed according to facility policy for admission timing.

Yes No N/A

Assessment documentation is signed and attributable to the correct clinician critical (required)

Confirm the record identifies the person who completed the assessment.

Yes No N/A

Admission skin assessment is complete and located in the correct chart section

Ensure the assessment is not fragmented across multiple locations without cross-reference.

Yes No N/A

Braden Score Assessment

Braden score documented on admission critical (required)

Confirm a Braden score was recorded as part of the admission assessment.

Yes No N/A

Braden subscales are fully completed

Check that all required subscales are present, including sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Yes No N/A

Risk level matches the documented Braden score

Verify the stated risk category aligns with the score entered.

Yes No N/A

Head-to-Toe Skin Inspection

Head-to-toe skin inspection documented as complete critical (required)

Confirm the assessment covers the entire body, not only selected areas.

Yes No N/A

High-risk pressure areas assessed and documented critical (required)

Review documentation for sacrum, heels, elbows, hips, occiput, and other facility-defined pressure points.

Yes No N/A

Any skin abnormalities are clearly described

Check that redness, bruising, tears, rashes, wounds, or moisture-associated damage are described with location and appearance.

Yes No N/A

Patient tolerance or limitations during assessment documented

Verify any refusal, pain, mobility limitation, or clinical barrier is noted.

Yes No N/A

Device-Related Skin Check

Medical devices present on admission were identified

Examples include oxygen tubing, braces, splints, catheters, dressings, and monitoring equipment.

Yes No N/A

Skin under and around devices was checked for pressure or irritation critical (required)

Confirm device-related pressure injury risk areas were inspected.

Yes No N/A

Device-related findings were documented with location and condition

Verify any redness, indentation, or breakdown related to devices is recorded clearly.

Yes No N/A

Photo Documentation and Follow-Up

Photos obtained for skin concerns per policy

Confirm photo documentation exists when wounds, pressure injuries, or notable skin findings are present.

Yes No N/A

Photo evidence (optional)

Consent or policy requirements for photos were followed

Check that photo capture complied with facility policy and patient consent requirements.

Yes No N/A

Escalation or wound care referral documented when indicated

Verify appropriate notification, consult, or follow-up plan was documented for abnormal findings.

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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