Pressure Injury Survey Guide

Conduct the Study - Chart Review



Pressure Injury Risk Status


Determine whether the patient is "At Risk" for pressure injury development based on the LAST pressure injury risk assessment.


Determination of patient risk status (at risk/not at risk) should follow guidelines established for the instrument used to assess pressure injury risk.

  • For the Braden Scale, a score of 18 or less indicates that the patient is at risk for pressure injuries
  • For the Norton Scale, a score of 15-16 or less indicates the patient is at risk for pressure injuries
  • For the Braden Q, a score of 16 or less indicates the patient is at risk for pressure injuries
  • For the NSRAS, a score of 13 or higher indicates the neonate is at risk for skin injury
  1. Ayello, E.A., & Braden, B. (2002). How and why to do pressure ulcer risk assessment. Advances in Skin & Wound Care, 15, 125-131.
  2. Curley, M.A., Razmus, I.S., Roberts, K.E., & Wypij, D. (2003). Predicting pressure ulcer risk in pediatric patients: the Braden Q Scale. Nursing Research, 52, 22-33.
  3. http://www.nichq.org/pdf/FINALPressureUlcers.pdf
  4. Norton, D. (1989). Calculating the risk: reflections on the Norton Scale. Decubitus, 2(3), 24-31.
  5. Chou, R., Dana, T., Bougatsos, C., Blazina, I., Starmer, A., Reitel, K., & Buckley, D. (2013, May). Pressure Ulcer Risk Assessment and Prevention: Comparative Effectiveness. Retrieved from http://www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=926
  6. Nixon, J., Cuddigan, J., & Haesler, E. (2014). Risk Factors and Risk Assessment. In E. Haesler (Ed.), Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline (pp. 42-61). Osborne Park, Western Australia: Cambridge Media.