1. Set up the project
Record the project title, lead, organisation, site, audit cycle, dates, sample size and local compliance target. Add the wards, departments, specialties and services in scope, and confirm the guidance and local policies you are auditing against.
2. Add your team
Add the project lead, clinical and educational supervisors, tissue viability contacts, data collectors and governance reviewers with their role in the project.
3. Confirm scope
Review inclusion and exclusion criteria with your team so records are selected consistently, and read through the 31 audit criteria before collecting data.
4. Collect data
Complete one structured form per eligible episode using a pseudonymised case reference. Record demographics, risk assessment details, skin assessment, prevention planning, equipment, reassessment and communication.
5. Review the dashboard
Check overall and criterion-level compliance, the run chart over time, the Pareto of non-compliance and breakdowns by ward, department, specialty, care setting and patient group.
6. Interpret findings
Use the Findings tab to record what is working well, where compliance is below target, variation between areas, documentation issues and any safety concerns.
7. Plan improvement
Turn findings into an improvement aim, an action plan with owners and target dates, PDSA cycles, a sustainability plan and a re-audit plan.
8. Generate outputs
Produce the Excel workbook, Word audit report, executive summary, governance report, ARCP evidence summary, PowerPoint presentation, PDF and CSV from the Export centre.
Frequently asked questions
Escalation reminder
Ensure any new pressure ulcer, suspected deep tissue injury, skin deterioration, pain over pressure areas, equipment delay, safeguarding concern, severe immobility risk, medical device pressure injury concern or pressure-ulcer-related patient safety concern is escalated through local nursing, tissue viability, clinical and governance pathways. Do not rely on this audit tool for urgent escalation or clinical decision-making.