Inclusion, exclusion and audit criteria

DEMO DATA

Confirm who is in scope before collecting data, then review the criteria each record is assessed against.

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Clinical purpose
This audit reviews whether adult patients have timely pressure ulcer risk assessment, documented risk category, appropriate skin assessment, risk reassessment after clinical change, and an individualised prevention plan where risk is identified. It focuses on admission or first contact risk assessment, use of a validated risk assessment tool where locally used, clinical judgement, skin inspection, mobility and repositioning needs, pressure redistribution equipment, nutrition and hydration risk, continence/moisture, cognitive impairment, existing or previous pressure damage, medical device-related pressure risk, documentation quality, escalation to tissue viability where required, and communication at discharge or transfer.
Inclusion criteria
Adapt locally where your organisation's policy differs.
  • Adults aged 16 years or older unless locally adapted
  • Adults admitted to secondary care
  • Adults admitted to care homes with nursing where NHS care is provided, if locally included
  • Adults receiving NHS care in ED, SDEC, primary, community or other settings where local policy requires risk assessment because risk factors are present
  • Adults with significantly limited mobility
  • Adults with significant loss of sensation
  • Adults with previous or current pressure ulcer
  • Adults with nutritional deficiency or malnutrition risk
  • Adults unable to reposition themselves
  • Adults with significant cognitive impairment
  • Adults with moisture, continence, medical device, frailty, end-of-life, sedation or critical illness risk where locally included
  • Patients managed in selected wards, units, departments or pathways
  • Electronic, paper or hybrid records depending on local setup
Exclusion criteria
Records meeting any of these should not be submitted.
  • Patients under 16 years old unless locally adapted
  • Maternity-specific pathways unless locally adapted
  • Paediatric pressure ulcer pathways unless locally adapted
  • Outpatient-only encounters where local policy does not require pressure ulcer risk assessment
  • Day-case or very short-stay cases where local policy excludes them
  • Patients already being audited under a separate specialist tissue viability incident review unless local scope includes them
  • Duplicate records or duplicate pressure ulcer risk assessment episodes
  • Records outside the selected audit period
  • Records unavailable for review
  • Cases where local governance approval is required but has not been obtained
  • Direct patient identifiers entered into the tool
Audit standards
Local audit standards derived from NICE CG179 and NICE QS89. Targets are editable local defaults, not mandatory national thresholds.
  • Eligible adult episodes with pressure ulcer risk assessment completed
    Target ≥ 90%
  • Risk assessment completed within the locally expected timeframe
    Target ≥ 90%
  • Risk score or risk category documented where applicable
    Target ≥ 90%
  • At-risk or high-risk patients with skin assessment documented where required
    Target ≥ 90%
  • At-risk or high-risk patients with an individualised prevention plan documented
    Target ≥ 90%
  • Repositioning needs documented where relevant
    Target ≥ 90%
  • Pressure redistribution equipment considered or provided where indicated
    Target ≥ 90%
  • Reassessment completed after clinical status change where required
    Target ≥ 90%
  • Risk status and prevention plan communicated at transfer or discharge where relevant
    Target ≥ 90%
  • Pressure-ulcer-related safety concerns escalated or actioned where identified
    Target ≥ 90%
Audit criteria (31)
Each record is assessed against these criteria. Compliance is calculated as Yes ÷ (Yes + No); "Not applicable" and "Unable to determine" are excluded.
  1. C1Pressure ulcer risk assessment was required according to local policy or risk factors.
  2. C2Pressure ulcer risk assessment was completed.
  3. C3Risk assessment was completed within the locally expected timeframe.
  4. C4Validated risk assessment tool or local assessment method was used where required.
  5. C5Risk score or risk category was documented where applicable.
  6. C6Clinical judgement was documented where relevant.
  7. C7Previous or current pressure ulcer status was checked and documented.
  8. C8Mobility and ability to reposition independently were assessed.
  9. C9Sensory impairment was considered where relevant.
  10. C10Nutritional risk was considered.
  11. C11Continence, moisture or skin exposure risk was considered.
  12. C12Cognitive impairment, delirium, dementia or ability to follow repositioning advice was considered where relevant.
  13. C13Medical device-related pressure risk was considered where relevant.
  14. C14Skin assessment was completed where risk or high risk was identified.
  15. C15Skin assessment included pressure areas relevant to the patient's risk.
  16. C16Skin colour change, discolouration, heat, firmness or moisture variation was documented where relevant.
  17. C17Existing pressure damage was classified or described according to local policy where present.
  18. C18Individualised pressure ulcer prevention plan was documented where risk was identified.
  19. C19Repositioning need and frequency were documented where relevant.
  20. C20Pressure redistribution equipment was considered or requested where indicated.
  21. C21Pressure redistribution equipment was provided within local expected timeframe where required.
  22. C22Heel protection or offloading was considered where relevant.
  23. C23Continence / moisture management plan was documented where relevant.
  24. C24Nutrition and hydration plan was documented where relevant.
  25. C25Tissue viability referral was completed where required by local policy or clinical risk.
  26. C26Pressure ulcer risk was reassessed after relevant clinical status change.
  27. C27Risk status and prevention plan were communicated during handover, transfer or discharge where relevant.
  28. C28Patient, family or carer advice on prevention was documented where appropriate.
  29. C29Reason for delayed, missing or incomplete risk assessment or prevention action was documented where applicable.
  30. C30Documentation was clear enough for another clinician or nurse to understand risk status, prevention plan, ownership and next actions.
  31. C31Any pressure-ulcer-related safety concern was escalated or actioned where identified.
Clinical safety note
This tool supports local audit, quality improvement and governance review. It does not replace clinical judgement, nursing assessment, tissue viability advice, local pressure ulcer prevention policy, safeguarding processes, incident reporting, wound assessment, medical device safety checks, nutritional assessment or emergency escalation pathways. Any new pressure damage, suspected deep tissue injury, deteriorating wound, pain, infection concern, safeguarding concern, unsafe equipment delay or serious patient safety concern must be escalated according to local policy. Do not enter patient names, NHS numbers, hospital numbers, full dates of birth, addresses or other direct identifiers.