Ward details

Ward name

Date & Time
Bed number



Pressure Ulcers

Please record the Category of the patients WORST Old and New pressure ulcers

Old pressure ulcers: developed within 72 hours of admission to Trust

Old pressure ulcer photo

New pressure ulcers: developed 72 or more hours after admission

New pressure ulcer photo

Record the severity of any fall that the patient has experienced in previous 72 hours in a care setting (this includes at home if on a district nursing caseload)

Falls severity
Urinary tract infections

Select OLD UTI if treatment began before admission - or NEW if after admission

OLD or NEW urinary infection

If patient has had a urinary catheter during the last 72 hours, select the number of days it was in place

Number of days catheter in place

VTE assessment and management

Has a VTE Assessment been done?

Has VTE prophylaxis started if at risk?

VTE Treatment - if the patient is being treated for VTE, choose type of VTE (Old categories for VTE before admission)
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.