Pressure Injury Survey - Monthly Report

(For data collection purposes only)

Date:

NDNQI® Hospital Code:

Unit Name:

Month: Date of Survey

Report for Year & Quarter:

Unit Census:
Number Surveyed:_____ Number Excluded: _____ Not on Unit_____ Refused_____ Unsafe for Pt._____ Actively Dying_____

Unit Acquired Injury Reporting: ____ Yes ____ No

_____Braden(B*) _____Braden Q(BQ*) _____NSRAS(NS*) _____Multiple Scales
Risk Assessment (RA*) Scale Used
on This Unit: _____BradenQD(BQD*) _____Norton(N*) _____Other(O*) Clinical Factors (CL*)

Pt. ____ Pt. ____ Pt. ____ Pt. ____ Pt. ____ Pt. ____ Pt. ____ Pt. ____ Pt. ____ Pt. ____

Patient Number
List years, months, days, and/or gestational age
Patient Age
at birth as appropriate
Demographics
Gender F=Female / M=Male

Skin Assessment Y=Yes /N=No /P=Pending

Risk Assessment Y=Yes /N=No /P=Pending

Admission
Assessment
Indicate RA* Scale or if O*/CL* used
Scale & Score
RA* Score (Only if used B*, BQ*, BQD*, NS*, N*)

>0-12 Hours
>12-24 Hours
>24-48 Hours
Time Since Last
Pressure Injury >48-72 Hours
Risk Assessment
(check one) >72 Hours - 1 Week
Last > 1 Week
Assessment*
Never assessed for risk (avail. if adm. risk = No;
skip to # of pressure injuries)
Indicate RA* Scale or if O*/CL* used
Scale & Score
RA* Score (Only if used B*, BQ*, BQD*, NS*, N*)

Patient at Risk YRA=Yes for RA* score/ YCL=Yes for CL*/ N=No

Prevention in Use Y=Yes/ N=No/ P=Pending

Y=Yes N=No D=Documented

Skin Assessment
Contraindication

Pressure
Y=Yes N=No D=Documented Contraindication
Redistribution
Types of U=Unnecessary for Patient P=Pt. Refused
Surface
Prevention
Interventions In
Use Within Past Y=Yes N=No D=Documented Contraindication
Repositioning
24 Hours for At- U=Unnecessary for Patient P=Pt. Refused
Risk Patients
only
Y=Yes N=No D=Documented Contraindication
Nutritional Support
U=Unnecessary for Patient P=Pt. Refused

Moisture Y=Yes N=No D=Documented Contraindication

Management U=Unnecessary for Patient P=Pt. Refused

Total

Each Patient Hospital Acquired (this unit &/or other unit)

Unit Acquired (this unit only)

Stage 1
Stage 2
Stage 3
Stage 4
At Each Stage of
# of Pressure
Hospital / Unit Unstageable
Injuries*
Acquired Injuries
DTPI (Deep Tissue Pressure Injury)

Mucosal Membrane PI

Non-Visible Pressure Injury

Total number of Hospital Acquired Pressure

Medical Device Injuries Related to a Medical Device
Related Pressure
Injuries Total number of Unit Acquired Pressure Injuries
Related to a Medical Device
*=Required
 Patient Number

List yrs, mos, days, &/or gest age at birth as appropriate Age

Date:
F=Female / M=Male Gender

Unit Name:
Unit Census:
Y=Yes /N=No Restraint In Use

Limb
Restraint Type
Vest
(check all that apply)

© 2020 Press Ganey Associates LLC

(For data collection purposes only)

Other

Acute Med/Surg

Behavioral Restraint
Unit Acquired Pressure Injury Reporting:

Category
Other (check one)
Risk Assessment (RA*) Scale Used on This Unit:

Unknown

Prevent falls/getting out of bed Restraint Survey

Yes

Prevent removing equipment/therapies

For Year:

Clinical
No

Reduce harm to self

Justification for
Hospital ID Code:

Restraint (check
Number Surveyed:

Reduce harm to others

all that apply)
Braden (B*)

Other

Unknown

Y=Yes /N=No /P=Pending Skin Assessment

Y=Yes /N=No /P=Pending Risk Assessment

Indicate RA* Scale or if O*/CL* used

BradenQ (BQ*)

Admission
Assessment

Scale & Score

RA* Score (Only if used B*, BQ*, BQD*, NS*, N*)
>0-12 Hours

>12-24 Hours
For Month:

>24-48 Hours
Number Excluded:

>48-72 Hours Time Since Last

Pressure Injury RA*
>72 Hours - 1 Week (check one)
Braden QD (BQD*)

> 1 Week

Never assessed for risk (skip to # Pressure

Last Assessment

Injuries)
Not on Unit:

Indicate RA* Scale or if O*/CL* used

Scale & Score
RA* Score (Only if used B*, BQ*, BQD*, NS*, N*)

YRA=Yes for RA* score /YCL=Yes for CL* /N=No Patient at Risk
NSRAS (NS*)
Refused:

Y=Yes /N=No /P=Pending Prevention in Use

Y=Yes/ N=No /D=Documented Contraindication Skin Assessment

Y=Yes /N=No /D=Documented Contraindication Pressure

/U=Unnecessary for Pt. /P=Pt. Refused Redistribution
Surface
Norton (N*)
Restraint & Pressure Injury Survey - Monthly Report

Unsafe for Pt.:

Y=Yes /N=No /D=Documented Contraindication Repositioning

/U=Unnecessary for Pt. /P=Pt. Refused

Y=Yes /N=No /D=Documented Contraindication Nutritional

/U=Unnecessary for Pt. /P=Pt. Refused Support
Pressure Injury Survey

Past 24 Hours for At Risk Patients only

Y=Yes /N=No /D=Documented Contraindication Moisture

/U=Unnecessary for Pt. /P=Pt. Refused Management
Types of Prevention Interventions In Use Within

Total
Actively Dying:

Multiple Scales

Hospital Acquired (this unit &/or other unit) Each Patient

Unit Acquired (this unit only)

Stage 1

Stage 2

Stage 3
See NDNQI® Guidelines for data collection directions. See Pressure Injury Training on how to stage pressure injuries and differentiate from other types of wounds.

Stage 4
At Each Stage of
Clinical Factors (CL*)

Unstageable PI Hospital / Unit

Acquired Pressure
Deep Tissue Pressure Injury (DTPI) Injuries

Mucosal Membrane Pressure Injury

# of Pressure Injuries
 At Each Stage of
Hospital / Unit
Acquired Pressure
Injuries

# of Pressure Injuries
Non-Visible pressure injury