Bed sore documentation checklist
Nursing Home Reporter
What families often gather before talking with an attorney about pressure ulcers in a nursing home.

Photos and dates
Document skin changes carefully without delaying medical care.
[ ] Date-stamped photos of the wound area (same angle when possible)
[ ] Notes on size, color, odor, drainage, and pain
[ ] When staff first mentioned the sore vs when you noticed it

Medical and facility records
Ask in writing for records; keep copies of every request.
[ ] Hospital ER and wound-care notes
[ ] Nursing home care plans and turn schedules
[ ] Weight logs, nutrition notes, and skin assessments
[ ] Names of nurses/aides on relevant shifts

Inspection context
Pull the facility report card on this site and note recent skin-integrity or quality-of-care deficiencies.
[ ] Abuse icon or special-focus status if present
[ ] Recent F686 / pressure-ulcer related citations
[ ] Staffing rating and nurse hours if unusually low

Sources
HHS: access to medical records: https://www.hhs.gov/hipaa/for-individuals/medical-records/index.html
MedlinePlus: pressure sores: https://medlineplus.gov/pressuresores.html

Informational only. Nursing Home Reporter is not a law firm. Inspection history does not prove liability. Obtain medical care for an active injury.
https://www.nursinghomereporter.com/guides/bed-sore-documentation-checklist