Skin Assessment Form – Fill Out and Use

Licensed Nurse Weekly Skin Assessment

RESIDENT: ______________________________________________________________ DATE:____________________ ROOM #:_________________

his form should be completed weekly on all residents per facility policy. Any areas of skin requiring treatment should have a thorough record of documentation in addition to this form located elsewhere in the chart per facility protocol. Check “Yes” or “No” if the item relects the resident’s assessment. If the answer is “yes” to 3 or more of the items listed below, consider implementation of the “Skin Tear Prevention Protocol.” Review the care plan to ensure skin care is included as necessary.

If any questions are answered “yes,” indicate location on body outline with number of question.

Licensed Nurse Signature: _________________________________________________ Date: __________________

Document available at www.primaris.org

MO-08-09-PU MAY 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily relect CMS policy. Adapted from Ratlif Care Center.