Pressure injuries are a significant quality indicator for skilled nursing facilities. Proper documentation demonstrates that facilities are providing appropriate preventive care and responding to changes in condition.
What Documentation Should Include
Risk Assessment Documentation
- • Braden Scale or other validated assessment scores
- • Frequency of assessments (admission, weekly, with condition changes)
- • Specific risk factors identified
Prevention Interventions
- • Repositioning schedule and compliance
- • Pressure-relieving devices in use
- • Nutrition and hydration interventions
- • Skin inspection frequency and findings
Outcome Monitoring
- • Wound measurements and staging (if applicable)
- • Treatment effectiveness documentation
- • Care plan updates based on outcomes
F684 Connection: Quality of care citations often relate to inadequate pressure injury prevention. Surveyors look for evidence that facilities identified risk, implemented appropriate interventions, and monitored outcomes.
How QAPIShield Supports Documentation
- Automated risk scoring based on clinical inputs
- AI-generated care plan interventions
- Documentation-ready outputs for survey review
