Patient/Resident Label
Name:_________________________________
DOB:__________________________________
Handoff Dataset Elements
Pressure-Related Wound(s) or Deep Tissue Injuries
No current wound, but HIGH ALERT due to____________________________________________
Wound Location __________________________
Date of onset ______/______/______
Present on admission
Description of the Wound: Wound Care Consult/Progress Note?
Yes (attach)
Intact skin with nonblanchable redness of a localized area (Stage I)
Partial thickness loss of dermis (Stage II)
Full thickness tissue loss (Stage III)
Full thickness loss with exposed bone, tendon, or muscle (Stage IV)
Full thickness loss in which base of the ulcer is covered by slough (Unstageable)
Suspected deep tissue injury
No
Size (centimeters: length x width x depth) _______________ Date of last measurement ___/___/___
Length: longest length from head to toe
Width: Widest width of the same pressure ulcer, side-to-side perpendicular (90-degree angle) to length
Depth: Depth of the same pressure ulcer from the visible surface to the deepest area
Size from last measurement
Improving
Unchanged
Worsening
Tunneling/Sinus Tracks Location (use clock face): ______________ Length: _______________
Mobility Status (ability to change & control body position) Last Braden Score for Mobility _______ or
Does not make even slight changes in position without assistance (Completely Immobile)
Makes occasional slight changes in position, unable to make frequent/significant changes in position
independently (Very Limited)
Makes frequent though slight changes in position independently (Slightly Limited)
Makes major and frequent changes in position without assistance (No Limitation)
Nutrition Status (usual food intake pattern) Last Braden Score for Nutrition _______ or
Never eats complete meal, does not take liquid dietary supplement OR
NPO or clear liquids for > 5 days (Very Poor)
Rarely eats complete meal, dietary supplement occasionally OR
receives less than optimum amount of liquid diet or tube feeding (Probably Inadequate)
Eats over half of most meals OR is on tube feeding/TPN meeting most nutritional needs (Adequate)
Eats most of every meal (Excellent)
Nutritional Consult
Continent
Yes
Yes (if yes, attach copy of consult note)
No
Treatment goal:
Healing
Current Treatment Plan send
Skin flow sheet
No
Bowel or Bladder
Palliative
Maintenance
Physician orders
MAR
TAR
Diabetic
PT/INR flow sheets
Date of last dressing change ______/______/______
Pre-medication required
Yes
No
Pressure redistribution/DME
Bed Type __________
Negative Pressure Wound Therapy
Other
Chair/Cushion Type __________
Lab Values/Dates (send upon Hospital discharge or Nursing Home discharge to ALF/Home Health)
Hemoglobin
Hematocrit
WBC
Glucose or HBA1c
Pre-albumin, Albumin
Nurse Name & Signature____________________________________________ Date:_____________
June 2009
Revised 10/25/10
Developed by Oregon Pressure Ulcer Advisory Panel.
Endorsed by the Advancing Excellence and Oregon IHI Network Joint Committee.