Pressure Injury Assessment & Staging Note

Date/Time of Assessment: [date and time]

Care Setting: [acute care / long-term care / skilled nursing facility / home health / outpatient clinic / other]

Clinician: [name, credentials]

Reason for Note: [initial staging / reassessment / deterioration / admission baseline / device-related concern]

(When information is unavailable, document explicitly rather than omitting. Do not infer stage from treatment; support staging with exam findings. Once a pressure injury is staged as full-thickness (Stage 3 or 4), do not downstage during healing; use "healing Stage X pressure injury" with current wound bed description. For stable, dry, adherent heel eschar without signs of infection, document the decision to monitor rather than debride.)

Risk Profile

[Concise summary of pressure injury risk drivers including mobility/activity status, sensory impairment, moisture exposure, perfusion concerns, nutrition risk indicators, and devices contacting skin or mucosa under pressure] (If a standardized risk tool score is available, include tool name and total score with subscales of concern. If clinician judgment overrides the tool score, briefly state why.)

Skin Inspection Summary

[Total pressure injuries identified, most severe stage present, and whether any are suspected device-related; high-risk anatomical sites assessed; non-pressure skin findings if present, noted without staging]

Pressure Injury Record

(Repeat the following wound block once for each confirmed pressure injury. Use a stable identifier for each wound and maintain consistency across encounters.)

[Wound ID]

Wound ID: [e.g., PI-01]

Location: [anatomic site with laterality and surface]

Onset: [date first noted / present on first assessment]

Present on Admission: [Yes / No / N/A]

Stage: [Stage 1 / Stage 2 / Stage 3 / Stage 4 / Unstageable / Deep Tissue Pressure Injury / Mucosal Membrane PI (not staged)]

Staging Rationale: [2–4 concise, objective findings supporting the selected stage] (For Stage 2, explicitly exclude moisture-associated dermatitis, adhesive injury, or skin tear when relevant. For Unstageable, note slough/eschar obscuring depth. For DTPI, note persistent deep purple/maroon discoloration with firmness or boggy texture. For Stage 4, specify exposed deep structures.)

Measurements (cm): [length × width × depth as applicable; undermining and tunneling with depth and clock-face positions if present; measurement method and limitations if exact measurement not possible]

Wound Characteristics:

• Wound bed: [tissue composition with percentages as applicable; exposed structures if any]
• Exudate: [amount, type, odor]
• Edges and periwound: [edge characteristics; periwound skin condition]

Pain: [rest score]; [score with care]; [analgesia needs for procedures]

Infection Screening: [local and systemic signs if present; state "concern for infection" with planned evaluation if applicable; do not label as infection unless diagnosed]

Device-Related: [Yes / No / N/A] (If yes, specify device name/type, fit/securement assessment, and mitigation actions. For mucosal membrane PI, specify device and mucosal site.)

Current Treatment: [cleansing agent/method]; [dressing type and change frequency]; [offloading/pressure relief method]; [adherence status and barriers if refusal]

Progress: [improved / stable / worsened] — [brief description of changes from prior assessment]

(If lesion etiology is uncertain, document as "Skin breakdown—etiology uncertain" with differential considerations and re-evaluation plan. Do not assign a pressure injury stage if confidence is low.)

Plan

• Pressure Redistribution: [turn/reposition schedule; positioning precautions; heel offloading; sitting limits and weight-shift plan; device rotation and skin check frequency]
• Support Surface: [mattress and cushion type with rationale tied to risk/stage]
• Moisture Management: [incontinence care; barrier products; perspiration/drainage control]
• Nutrition: [screening outcome; dietitian consult status; protein/calorie strategy; weight monitoring; alignment with goals of care if applicable]
• Wound Care: [cleansing and dressing plan with frequency; debridement plan if indicated; stable heel eschar decision if applicable; procedural pain management]
• Escalation Triggers: [specific conditions warranting escalation and relevant consults to consider]
• Patient/Caregiver Education: [topics covered; teach-back status; refusals with patient-stated barriers]

Summary

[List each active pressure injury by Wound ID, location, and stage; state highest stage present, key ongoing risks, and follow-up/reassessment interval]

Clinician Signature: [name, credentials, date/time]