Braden Scale for Pressure Injury Risk
Predicts pressure injury risk to guide prevention interventions in hospitalized and immobilized patients
- Highest activation tier
- Mandatory
- How it is scored
- Scored in code; a detected disagreeing draft value is flagged for correction
- Scoring type
- point sum
- Care settings
- ICU, Inpatient
When it activates
Scribeable activates a calculator from the encounter. The Braden Scale for Pressure Injury Risk can activate when the transcript or pasted chart context documents any of these:
- Pressure injury risk assessment
- Immobilized patient skin evaluation
- Admission skin assessment
- Wound prevention planning
- ICU skin integrity monitoring
Inputs the note needs
6 inputs. Each is resolved from the transcript, the pasted chart context and charted labs; an input marked "asks you" is requested as a clarification when it is undocumented.
| Input | Type | Unit / options | Guidance |
|---|---|---|---|
| Ability to respond to pressure-related discomfort: 1=completely limited, 2=very limited, 3=slightly limited, 4=no impairment | exam | ||
| Degree to which skin is exposed to moisture: 1=constantly moist, 2=very moist, 3=occasionally moist, 4=rarely moist | exam | ||
| Degree of physical activity: 1=bedfast, 2=chairfast, 3=walks occasionally, 4=walks frequently | history | ||
| Ability to change and control body position: 1=completely immobile, 2=very limited, 3=slightly limited, 4=no limitations | exam | ||
| Usual food intake pattern: 1=very poor, 2=probably inadequate, 3=adequate, 4=excellent | history | ||
| Friction and shear: 1=problem, 2=potential problem, 3=no apparent problem | exam |
Scoring
6 subscales: Sensory perception (1-4), Moisture (1-4), Activity (1-4), Mobility (1-4), Nutrition (1-4), Friction/shear (1-3). Total range 6-23. Lower scores = higher risk.
Sensory Ability to respond to pressure-related discomfort: 1=completely limited, 2=very limited, 3=slightly limited, 4=no impairment + Moisture Degree to which skin is exposed to moisture: 1=constantly moist, 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 Friction and shear: 1=problem, 2=potential problem, 3=no apparent problem
Interpretation
<=9: Very high risk — aggressive prevention (specialty surface, frequent repositioning q1-2h, nutrition consult, wound care consult). 10-12: High risk — pressure redistribution surface, reposition q2h, moisture management. 13-14: Moderate risk — reposition q2h, optimize nutrition, skin inspection. 15-18: Mild risk — standard prevention measures. >=19: No significant risk — reassess with status changes. Reassess on admission, routinely (daily in ICU, weekly on floor), and with condition changes.
Evidence
Sources carried in Scribeable's citation registry for this calculator; guideline version: Bergstrom 1987.
- Bergstrom N et al. The Braden Scale for Predicting Pressure Sore RiskBergstrom et al. (Braden) 1987 · 1987 · Level I · link last verified 2026-03-28
How Scribeable handles it in the note
When an encounter activates the Braden Scale for Pressure Injury Risk at the mandatory tier, Scribeable resolves its inputs from the transcript, the pasted chart context and any charted labs, and asks you for a missing input you can supply before the note is finalised. Bedside-exam and separately ordered study values are not requested one input at a time; a calculator that carries a combined clarification question may still put that single question to you.
The score is computed in code from the resolved inputs, not recalled by the language model. If the draft states a Braden Scale for Pressure Injury Risk value that disagrees with the computed one, the disagreement is flagged to the second drafting pass, which is instructed to correct the score and its interpretation before you see the note.
Classified as a risk score: activated strictly, by a documented trigger, never by a permissive reading of the encounter.
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