OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare

Patient Name_____________________________________________Date:_____/_____/_____
9
2. Very Moist
3. Occasionally Moist
4. Rarely Moist
Activity: Degree of physical activity 1. Bedfast __________
2. Chairfast
3. Walks Occasionally
4. Walks Frequently
Mobility: Ability to change and control body position. 1. Completely Immobile __________
2. Very Limited
3. Slightly Limited
4. No Limitations
Nutrition: Usual food intake pattern. 1. Very Poor __________
2. Probably Inadequate
3. Adequate
4. Excellent
Friction/Shear: 1. Problem ___________
2. Potential Problem
3. No Apparent Problem
Total Branden Risk Score
_____________
Total Branden Risk Score
_____________
BRADEN SCORING: Patients with a score of 16 or less are considered to be at risk of developing pressure ulcers. (15 or 16 +
low risk; 13 or 14+ moderate risk; 12 or less + high risk)
Do you want to attach the Mini Nutritional (MNA) Assessment as a secondary profile
M1306-Does this patient have a least one Unhealed Pressure Ulcer at Stage 11 or Higher or designated as “unstageable”
0-No (go to M1322)
1-Yes
M1308-Current Numbers of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage: (Enter “0" if none; excludes Stage 1
pressure ulcers)
Column 1
Complete at
SOC/ROC/FU/DC
Stage description
Number Currently
Unhealed pressure ulcers
Present
a. Stage 11: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough, May
also present as an intact or open/ruptured serum-filled blister.
Column 1: _______ Column 2: _____
b. Stage 111: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough
may be present but does not obscure the depth of tissues loss. May include undermining and tunneling.
Column 1: _______ Column 2: _____
c. Stage IV: Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.
Column 1: _______ Column 2: _____
d1. Unstageable: Known or likely but unstageable due to non-removable dressing or device.