Case Study Data Collection Form

Name

Title

Commencement Date of Data Collection

Patient Initials

Healthcare Facility

Room

Unit

Age

Sex

Weight

Height

Date of Admission

Primary Diagnosis

Secondary Conditions

Waterlow/Braden Score

What type of mattress was used prior to case study commencement- foam or air?

Mattress used during Case Study

Amount Of Time in Bed

Frequency of turning/repositioning

Date of Assessment

Other Services Utilised (e.g. PT, OT,nutritional)

Presence of Existing Pressure Ulcer (Y/N) (If yes, was it measured & photographed?)

Date of Assessment

Amount Of Time in Chair

Chair Surface (Cushion Type)

Patient or Resident Satisfaction

Patient Comments

Staff Comments

Investigator Comments

Any Further Comments