How to chart a skin assessment

1. Inspect skin with privacy and good light — head-to-toe as the visit allows. Prioritize pressure points: sacrum/coccyx, heels, hips/trochanters, elbows, ears, occiput, and any device contact (O₂ tubing, TED/SCD edges, braces, wheelchair cushions, hearing aids).
2. Look for breaks, rashes, bruises, surgical incisions, and wounds/ulcers. Gently part skin folds (under breasts, abdominal pannus, groin, contracture creases) — soap and moisture hide there.
3. This field is multi-select — pick every chip that fits. No breaks or lesions of concern → Intact alone. Rash and Bruise are separate chips (pick one or both). Surgical incision → Incision; open wound or pressure ulcer/injury → Wound / ulcer; something else (drain site, tube site skin, burn, etc.) → Other + details in the wound/skin note.
4. Don’t stack Intact with other chips.
5. If wound or incision → set Wound / incision present to Yes and open Wound Assessment (button beside that field) for location, type, drainage, measurements. Rash/bruise detail goes in Skin note — not Wound Assessment.
6. New open area, expanding redness, hot swollen joint/skin, or wound with fever → escalate. Do not stage a pressure injury beyond what you are taught/allowed; describe what you see. Practice pressure-risk thinking on the left-rail Better Charting Skin Risk tool — an original Better Charting practice tool.
7. Timing: do a brief skin check on morning rounds; save the full head-to-toe skin assessment for daily bathing or showering when gown/clothes are off and you can see pressure points, folds, and device edges for real.

Bedside pearl: Brief skin check on morning rounds; full skin assessment during daily bathing or showering — that’s when you really see pressure points, folds, and device edges. Pull the TED hose down, lift the O₂ tubing off the ears, and check the heel floating off the mattress.

• Intact skin is the body’s barrier.
• Pressure over bony prominences reduces blood flow; enough time and pressure produce injury from non-blanchable redness to open ulcers.
• Friction and shear tear or shift tissue.
• Moisture (sweat, urine, wound drainage) softens skin and speeds breakdown in folds.
• Incisions are planned breaks closed surgically.
• Describe location, open vs closed, drainage, and surrounding skin — leave formal wound diagnosis and staging to instructor / facility rules.