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
