Table 4.

MDS (to be incorporated in RAF)

Screening Stage

Mobility:

a. Does the patient walk without help?

b. Does the patient change position?

PU status:

a. Current PU (≥1 category)

b. Reported history of PU

Detailed Full Assessment stage

Immobility items to incorporate the frequency of independent movement, e.g.:

a. Doesn't move

b. Moves occasionally

c. Moves frequently

Immobility items to incorporate the magnitude of independent movement, e.g.:

a. Doesn't move

b. Slight position changes

c. Major position changes

Immobility items to incorporate general, clinically relevant descriptions of movement, e.g.:

a. Bedfast

b. Chairfast

c. Walks with assistance

Sensory perception:

a. Does the patient feel and respond appropriately to discomfort from pressure

PU (existing and previous PU):

a. Category of PU (where possible for previous PU)

b. Site of PU

c. Presence of scar tissue (for previous PU)

General skin status:

a. Confirmation of vulnerable skin, e.g. dryness, paper thin and redness

b. Pressure area skin site

Perfusion:

a. Conditions affecting central circulation, e.g. shock, heart failure and hypotension

b. Conditions affecting peripheral circulation, e.g. peripheral vascular/arterial disease.

Diabetes:

a. Presence of diabetes

Moisture:

a. Presence of moisture due to perspiration, urine, faeces or exudate.

Frequency:

b. Frequent (1 or 2 times a day)

c. Constant

Nutrition:

a. Unplanned weight loss

b. Poor nutritional intake

c. Low BMI

d. High BMI