Last updated on 4/28/26 | First published on 4/28/26 | Literature review current through Mar. 2026
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Authors:
Elaine Horibe Song MD, PhD, MBA,
Kim Simonson RN-BC, ACHRN, CWS, FACCWS,
Tiffany Hamm BSN, RN, CWS, ACHRN, UHMSADS,
Topic editors:
Cathy Milne APRN, MSN, CWOCN-AP,
Nataliya Lebedinskaya RN, BSN, CWOCN,
more...
Coauthor(s)
Elaine Horibe Song, MD, PhD, MBACo-Founder and Editor, Wound Reference, Inc;
Professor (Affiliate), Division of Plastic Surgery, Federal University of Sao Paulo;
Volunteer, Association for the Advancement of Wound Care;
Google Scholar Profile
Disclosures: Nothing to disclose
Tiffany Hamm, BSN, RN, CWS, ACHRN, UHMSADS
Chief Nursing Officer, Wound Reference, IncDisclosures: Nothing to disclose
Kim Simonson, RN-BC, ACHRN, CWS, FACCWS
Disclosures: Nothing to disclose
Editors
Nataliya Lebedinskaya, RN, BSN, CWOCN
Disclosures: Nothing to disclose
Cathy Milne, APRN, MSN, CWOCN-AP
Disclosures: Nothing to disclose
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INTRODUCTION
Overview
Pressure ulcers/injuries (PUs/PIs) remain a significant challenge in healthcare, contributing to patient harm, increased length of stay, and higher costs.[1][2]
In the United States, approximately 2.5 million patients develop PUs/PIs each year, resulting in an estimated 60,000 deaths and over $11 billion in treatment costs.[2] The Centers for Medicare & Medicaid Services (CMS) classifies PUs/PIs among hospital-acquired conditions (HACs), making prevention of hospital-acquired pressure injuries (HAPI) a key quality, safety, and reimbursement priority.[1][3]
Standardized, structured clinical documentation plays a central role in effective HAPI prevention. Staff nurses are uniquely positioned to lead these efforts through:
- Comprehensive skin and risk assessments for early identification of at-risk patients
- Timely initiation of evidence-based HAPI prevention care bundles
This topic provides practical structured clinical documentation templates to support consistent, audit-ready documentation and implementation of HAPI prevention workflows. Templates can be adapted to align with facility policies, regulatory requirements, and electronic health records (EHR) system capabilities.
For an evidence-based HAPI prevention policy and procedure template, see "Policy and Procedure: Pressure Injury Assessment, Treatment, and Prevention". For an introduction and framework for assessment of pressure ulcers/injuries, including epidemiology, risk factors, etiology, pathophysiology, history, physical examination, diagnosis, differential diagnoses, documentation and ICD-10 coding, refer to "Pressure Ulcers/Injuries - Introduction and Assessment". For clinical guidelines and quality measures, see "Pressure Ulcers/Injuries - Overview". For common classification systems with pictures and descriptions, see "Pressure Ulcers/Injuries - Classification/Staging". For management of pressure ulcers/injuries see "Pressure Ulcers/Injuries - Treatment". For prevention strategies, see "Pressure Ulcers/Injuries - Prevention". For best practices in care coordination, see "Pressure Ulcers/Injuries -Coordination of Care".
STRUCTURED CLINICAL DOCUMENTATION TEMPLATES AND ORDER SETS FOR HAPI PREVENTION
Documentation Template: Structured Risk and Skin Assessment and Wound Assessment for Staff Nurses
Template
- Structured Risk and Skin Assessment for Staff Nurses
Goal and Audience:
- This Documentation Template for Structured Pressure Ulcer/Injury Risk and Skin Assessment for Staff Nurses is designed for use by Staff Nurses (or equivalent clinical personnel) to standardize the documentation of wound assessments. Healthcare organizations are encouraged to adapt, modify, and customize this template to align with their specific facility policies, EHR system capabilities, and workflow requirements. This template is for internal use only.
Documentation Template: Wound Assessment for Staff Nurses
Template
- Wound Assessment for Staff Nurses
Goal and Audience
- This Documentation Template for Wound Assessment is designed for use by Staff Nurses (or equivalent clinical personnel) to standardize the documentation of wound assessments. Healthcare organizations are encouraged to adapt, modify, and customize this template to align with their specific facility policies, EHR system capabilities, and workflow requirements. This template is for internal use only.
Documentation Template: Hospital-Acquired Pressure Injury (HAPI) Prevention Order Set for Staff Nurses
Template
- Hospital-Acquired Pressure Injury (HAPI) Prevention Order Set for Staff Nurses
Goal and Audience
- This Documentation Template for Hospital-Acquired Pressure Injury (HAPI) Prevention Order Set is designed for use by Staff Nurses (or equivalent clinical personnel) to implement HAPI prevention bundles. Healthcare organizations are encouraged to adapt, modify, and customize this template to align with their specific facility policies, EMR system capabilities, and workflow requirements. This template is for internal use only.
- Notes:
- Program the EHR to automatically suggest or load the HAPI Prevention Order Set whenever a clinician charts a high-risk Braden Scale score (e.g., a score of 18 or less, Mobility/Activity/Sensory Perception Braden/Braden Q Subscore 2 or less, Moisture Risk Braden/Braden Q Subscore 3 or less, Friction/Shear Risk Braden/Braden Q Subscore 2 or less, Skin Risk Assessment of Very Poor and Probably Inadequate Intake)
- Refusal / Contraindication dropdowns: always include a field in the corresponding flowsheet or documentation side for why a bundle item was not done (e.g., "Patient refused," "Medically contraindicated due to spinal instability").
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