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The Braden Scale for Predicting Pressure Sore Risk is a copyrighted nursing instrument (Bergstrom, Braden, Laguzza, and Holman, 1987) that rates six subscales for a total of 6 to 23, lower meaning higher pressure injury risk. Bedside, long-term-care, and home health nurses use it to decide who needs prevention measures and which ones. This page covers how to document the score and the interventions it triggers, with a fictional sample.
Registered nurses at the bedside, in long-term care, and in home health, with licensed practical or vocational nurses where facility policy and state scope allow; no publisher qualification level applies, the licensor's training materials come with a Braden Scale II license, and the nurse who observed the patient enters the ratings
Wound, ostomy, and continence nurses and skin integrity teams, nurse managers and unit educators, attending physicians and advanced practice providers, dietitians and therapists, coders determining present-on-admission status, quality and patient safety staff, CMS and state surveyors, accreditation reviewers, and expert reviewers in pressure injury claims
4 to 10 chart lines (trigger and version, six subscale ratings and total, facility risk category, separate skin inspection, intervention for each low subscale, reassessment date) · 2 to 5 minutes by hand after the patient has been observed
Observer-rated pressure injury risk assessment (six subscales, five scored 1 to 4 and friction and shear 1 to 3, total 6 to 23, lower total meaning higher risk; risk categories set by facility protocol from the authors' recommendations)
Admission and transfer assessments in acute and critical care, scheduled reassessment under unit policy, change of condition, long-term care admission and periodic reassessment feeding MDS Section M, home health start of care and recertification, perioperative and rehabilitation admissions; the Braden Q and Braden QD in pediatrics
Bergstrom, Braden, Laguzza, and Holman (Nursing Research, 1987); copyrighted by Barbara Braden and Nancy Bergstrom, licensed since April 2021 through Health Sense Ai, an HD Nursing subsidiary; named by CMS and accreditation bodies only as an example of a validated tool and mandated by none; described here for documentation, no descriptors reproduced
The Braden Scale for Predicting Pressure Sore Risk is a nurse-rated instrument that estimates a patient's risk of developing a pressure injury. Barbara Braden and Nancy Bergstrom published the conceptual model in Rehabilitation Nursing in 1987 and, with Ann Laguzza and Victoria Holman, the instrument itself in Nursing Research the same year (volume 36, pages 205 to 210). It rates six subscales, named here by their published labels with the intent of each in original words: sensory perception (whether the patient can notice pressure discomfort and act on it or call for help), moisture (how wet the skin stays through the day), activity (how much the patient is up and about), mobility (how well the patient repositions without help), nutrition (how well the patient is actually eating), and friction and shear (how much the skin drags against bed and chair surfaces during movement and transfers). Five subscales are scored 1 to 4 and friction and shear 1 to 3, so the total runs from 6 to 23 and a lower total means higher risk. The descriptors that define each rating are the copyrighted text of the instrument and are not reproduced or paraphrased on this page; the licensed form is the source of record. The authors founded Prevention Plus to license the scale; on April 20, 2021 Health Sense Ai, a subsidiary of HD Nursing, completed its acquisition of Prevention Plus and announced that it would be the sole licensor going forward, and in 2022 it released the Braden Scale II, developed by Amy Hester in consultation with Braden and Bergstrom, with updated terminology and descriptors, available with a toolkit under a facility license. Two pediatric siblings have their own rights holder: the Braden Q (Curley and colleagues, Nursing Research, 2003), validated in children from about three weeks to eight years of age and adding a tissue perfusion and oxygenation subscale, and the Braden QD (Curley and colleagues, Journal of Pediatrics, 2018), validated from preterm infants through age 21 and built to capture medical-device-related as well as immobility-related risk.
The load-bearing fact for documentation is that the total is a risk signal and not a care plan. The authors, the Hartford Institute for Geriatric Nursing, and the international guideline bodies all say that a low rating on any single subscale should drive its own preventive measure regardless of the total, because two patients with the same total can reach it by different routes: one through immobility, another through moisture or poor intake. The scale also does not examine the skin. It predicts risk; a separate visual and tactile inspection establishes whether an injury already exists, and the pressure injury staging page covers how that finding is described. The risk categories attached to the total are conventions rather than part of the 1987 instrument: the original validation set its cutoff at 16, the 1998 multisite study by Bergstrom, Braden, Kemp, Champagne, and Ruby moved the best overall cutoff to 18 and found that reassessment 48 to 72 hours after admission predicted better than the admission score, a 2024 systematic review of 34 intensive care studies found most empirically derived ICU cutoffs in the range of 12 to 14, and the Cochrane review by Moore and Patton (2019) found no reliable evidence that a structured risk tool reduces pressure ulcer incidence compared with clinical judgment. None of that makes the scale useless; it means the value lies in what the ratings prompt a nurse to do and to write down. A home health agency may adopt the Braden under its own policy, but the current OASIS item set carries no named risk-tool item (the OASIS assessment page covers the items that do exist), and the Morse Fall Scale is the structural peer for the same lesson on the falls side: a risk total that must not be mistaken for a plan.
Bedside nurses on medical, surgical, orthopedic, and rehabilitation units chart it on admission, on transfer, at the interval unit policy sets, and whenever the patient's condition changes; critical care nurses chart it beside sedation and delirium scores such as the RASS and the CAM-ICU, where sedation, ventilation, and vasopressors cluster patients at high risk and make the subscale detail more useful than the total. Long-term care nurses use it at admission, at the reassessment interval the facility protocol sets, and with any change of condition, and the result informs MDS 3.0 item M0100 and the care plan that CMS surveyors read under F686. Home health nurses record it at the start of care and recertification under agency policy, together with the caregiver teaching it prompts. Wound, ostomy, and continence nurses and skin integrity teams audit the entries; nurse managers and educators calibrate raters; dietitians and therapists receive the referrals that low nutrition, mobility, and activity ratings generate; physicians and advanced practice providers document the diagnosis and present-on-admission status that a coder needs, which depend on the skin inspection rather than the score. The Braden page owns one job: the risk assessment, the numeric ratings, the facility's risk category, and the link from each low subscale to a preventive action and a reassessment date. Neighbors take over from there: an existing wound is described on the pressure injury staging page, the risk status and prevention regimen travel in the transfer of care summary and the discharge summary, a facility-acquired injury is reported through the incident report when policy treats it as an event, and the interdisciplinary plan the ratings feed belongs in the care coordination note.
No regulator prescribes a Braden note format, and no authority in the United States, Canada, or Australia requires the Braden by name; what exists is a copyrighted instrument, facility protocols that set the reassessment interval and the risk categories, and survey and coding rules that judge whether an identified risk led to action. What survives review is an entry that states the trigger and the version, records all six ratings with the total, names the facility category as policy, documents a separate skin and device-site inspection, ties every low subscale to a specific intervention that was actually delivered, records the patient's response, and sets the next reassessment date and the triggers that bring it forward. Each element below carries the pitfall that most often undermines it.
Trigger, timing, and version. Open with why the assessment is being done and which instrument was used: admission, transfer, the scheduled interval under a named policy, or a change in condition (new sedation or immobility, incontinence, falling intake, fever, surgery), then the version (original Braden Scale or Braden Scale II under the facility license), the date and time, and the rater. The 1998 multisite validation used admission and 48 to 72 hour reassessment, and CMS sets no interval; an every-shift or weekly schedule is the facility's policy and should be cited as such. When reassessment is triggered by a change, name the change, because that sentence is what turns a repeated number into evidence of monitoring. Pitfall: A time-stamped duplicate total with no trigger, or a note that presents the unit's every-shift schedule as a CMS requirement.
Six subscale ratings and the total. Enter all six ratings as numbers in the published order with the total, and keep them visible in the note or flowsheet, not just the total. The total conceals the mechanism, and the ratings are less reliable than they look: Kottner and Dassen found totals for the same nursing home residents differing by as much as nine points between trained raters, with sensory perception and nutrition the least reliable subscales, and Magnan and Maklebust found that 1,391 web-trained nurses classified risk correctly 82.6 percent of the time, with the mid-range hardest. Rate the patient you observed today; do not carry yesterday's ratings forward as a new assessment, and say in one clause what the low ratings rest on in ordinary clinical words (intake percentages, how the patient moved during care, continence episodes), never in the scale's descriptor language. Pitfall: "Braden 14" with no subscale ratings, or ratings auto-populated from the last shift and signed as a fresh assessment.
Facility risk category, named as policy. Write the category the facility protocol assigns to the total and cite the protocol, because the categories are conventions layered on the instrument rather than the instrument's own rule: the 1987 validation used a cutoff of 16, the 1998 and 2002 multisite studies supported 18, most empirically derived intensive care cutoffs fall around 12 to 14, and facilities adopt the authors' later graded recommendations in their own policies. A category tells the reader which protocol tier applies; it does not by itself prescribe a mattress or a turning interval, and a note that reads "Braden 14 therefore every two hours" should be written only when that linkage is literally the organization's approved protocol. Pitfall: A category presented as the scale's rule, or a single universal cutoff applied to an ICU patient whose unit has validated a different one.
Skin and device-site inspection, charted separately. Record a head-to-toe visual and tactile inspection of the pressure points and every device contact site as its own act, with the findings: intact, or the location, laterality, and description of any change. For darker skin tones, compare with the person's usual tone and palpate for warmth, firmness, and tenderness rather than relying on visible redness. The inspection, not the score, establishes whether an injury was present on admission, and an existing injury is staged and described under the staging conventions by the nurse and diagnosed by the provider; a coder may take the stage from nursing documentation but the diagnosis from the provider's note, so the two must agree. Pitfall: The Braden score charted as the skin assessment, or a sacral injury found on day four with no admission inspection to show it was not there.
An intervention for each low subscale. For every subscale rated low, name the measure actually started or continued and how it is delivered: for mobility and activity, the pressure redistribution surface by type, the repositioning schedule with the real interval and assistance level, heel offloading, and the mobilization plan; for moisture, the cause being managed, the cleansing and barrier regimen, and the continence or microclimate measures; for nutrition, intake monitoring, weights, and the dietitian referral, without equating a low rating with malnutrition; for friction and shear, the transfer technique and equipment and head-of-bed limits; for sensory perception, the surveillance and teaching added because the patient may not report discomfort. Do this even when the total sits above the facility threshold, which is the position of the authors, HIGN, and the international guideline, and write the schedule you actually use rather than one the total is assumed to dictate. Pitfall: "Prevention protocol initiated" or "skin bundle in place" with no intervention that answers a specific low rating.
Patient response, refusal, and preferences. Chart what was delivered and how the patient responded, and when repositioning or a device is declined, chart the offer, the patient's stated reason where appropriate, the education given, the alternatives offered or accepted, who was notified under policy, and the revised plan. The international guideline builds patient preference and comfort into repositioning decisions, and survey and serious-event frameworks recognize refusal and clinical instability as circumstances that require documentation when preventability is judged. The rating itself does not change because an intervention was refused; the feasibility of the plan does, and the note should say so. Pitfall: "Refused" with nothing after it, or a repositioning log showing care that the patient declined.
Reassessment date, triggers, and plan revision. Close with the next scheduled reassessment date under the policy and the changes that bring it forward: transfer, surgery, new sedation or immobility, new incontinence, falling intake or weight, fever or hemodynamic decline, and any new skin finding. When a total changes, say which subscale moved and why in clinical terms, and revise the plan to match; a score should improve only because the patient's condition improved, never because a better mattress was placed, since the scale rates the patient and not the interventions. Carry the risk status, the surface, and the regimen into the handoff and the transfer of care summary, because transitions are reassessment points in every guideline. Pitfall: "Continue to monitor" with no date, a total that "improved" after a mattress change, or a care plan never revised after the ratings moved.
BRADEN SCALE DOCUMENTATION BLOCK (risk assessment and linked plan)
Date / time: [ ] Setting: [ ] Rater: [ ]
Trigger: [admission / transfer / scheduled per policy (name it) / change of
condition (state the change)]
Version: [original Braden Scale / Braden Scale II under facility license]
Subscale ratings (numbers only): sensory perception [ ] moisture [ ]
activity [ ] mobility [ ] nutrition [ ] friction and shear [ ]
Total: [ ] of 23 Prior total and date: [ ] Subscale that changed: [ ]
Basis for the low ratings (plain clinical facts): [intake percentages, weights,
observed movement during care, continence episodes, sedation]
Facility risk category: [ ] per [protocol name]; categories are policy, not
the scale's rule
Skin and device-site inspection (separate act): [pressure points and each
device site; intact or location, laterality, description; present on
admission determination; staging documented separately if an injury exists]
Interventions by low subscale (what is actually in place):
mobility / activity: [surface type; repositioning interval and assist level;
heel offloading; mobilization plan]
moisture: [cause managed; cleansing and barrier regimen; continence plan]
nutrition: [intake monitoring; weights; dietitian referral and date]
friction and shear: [transfer technique and equipment; head-of-bed limit]
sensory perception: [surveillance; patient and caregiver teaching]
Patient response: [accepted / declined: offer, reason, education, alternatives,
who was notified, plan revised]
Reassessment: [next date per policy; earlier if ...] Care plan revised: [ ]
Communication: [provider, dietitian, therapy, skin team, handoff, MDS or OASIS]
Clinician signature / credentials: Date:Free to use and share, no signup. The PDF includes a one-page cheat sheet with element-by-element pitfalls and a pre-sign checklist; the DOCX is the blank documentation block, ready to adapt. Neither reproduces the scale's subscale descriptors or rating anchors.
Scenario: a US skilled nursing facility's scheduled weekly Braden reassessment, three weeks after an 84-year-old resident's admission following hip fracture repair; the nurse records all six ratings, finds that only the nutrition rating has fallen, names the facility's risk category as policy, charts a separate skin inspection, ties the changed rating to a dated dietitian referral, and resets the reassessment. All details are fictional.
Patient: E.W., 84 · Setting: Skilled nursing facility, long-term care unit; scheduled weekly reassessment · Clinician: M. Okafor, RN · Note date: 09/17/2026
Trigger, version, and rater: Scheduled weekly reassessment, week three of the four weekly reassessments the facility's pressure injury prevention policy (NSG-114) requires after admission; the interval is facility policy, not a CMS requirement. Original Braden Scale as built in the facility's electronic record, rated by M. Okafor, RN, at 09:40 on 09/17/2026 after morning care and after review of the meal intake and weight records for 09/10/2026 through 09/17/2026. Prior totals on the same instrument: 15 on admission 08/27/2026 (admitted after right hip fracture repair in late August), 15 on 09/03/2026, 15 on 09/10/2026.
Ratings and total: Sensory perception 3, moisture 3, activity 2, mobility 2, nutrition 2, friction and shear 2; total 14 of 23 (15 on 09/10/2026). The only change is nutrition, from 3 to 2. Basis in the record: meal intake documented at 25 to 50 percent for 11 of the 21 meals since 09/10/2026 and refused at 3 of them, against 75 percent or more at most meals the week before; weight 61.2 kg today against 62.6 kg on 08/27/2026, a 2.2 percent loss; E.W. reports poor appetite and intermittent nausea since a new medication was started on 09/08/2026. The unchanged ratings rest on the same observations as last week: she transfers bed to wheelchair with two-person assist and a slide sheet, shifts her weight in the chair when prompted, spends about six hours a day in the wheelchair and walks 15 meters in therapy with a walker and standby assist, is continent of bowel and of bladder apart from occasional nighttime urgency, and reports discomfort reliably.
Facility risk category: Moderate risk under NSG-114, which sets its categories by total from the authors' published recommendations; last week's total placed her in the policy's at-risk tier. The category selects the protocol tier that applies. The interventions below answer the individual ratings, and this note applies the protocol without restating it.
Skin and device-site inspection (separate act): Head-to-toe visual and tactile inspection completed with morning care at 08:30: sacrum, coccyx, both ischial tuberosities, both trochanters, both heels, elbows, scapulae, and occiput intact, with no discoloration, warmth, or induration on palpation; light skin tone; right hip incision healed with no erythema; hearing aid contact sites and eyeglass bridge intact. No pressure injury. Unchanged from the admission inspection of 08/27/2026, which documented intact skin at every site. Staging not applicable.
Interventions by low subscale: Nutrition (2, changed): dietitian referral entered 09/17/2026 at 10:15 for assessment within 72 hours per policy; meal intake to be recorded at every meal and reviewed daily; weekly weights continued, next on 09/24/2026; mid-morning and evening snacks offered daily in line with her stated preference for smaller, more frequent meals; attending notified by secure message at 10:40 of the appetite change following the 09/08/2026 medication start, order for the dietitian consult received at 13:15, medication review requested; daughter (health care representative) informed by phone at 14:05. Mobility and activity (2, unchanged): pressure redistribution foam mattress in place since admission; assisted repositioning every three hours overnight on the individualized schedule agreed with E.W. on 08/28/2026 (the policy default of every two hours was relaxed to three at her request, with intact skin at every weekly inspection since); weight shift at least hourly in the wheelchair on a pressure redistribution cushion; heels floated on a pillow under the calves in bed; therapy five days a week continuing. Friction and shear (2, unchanged): two-person assist with a slide sheet for bed repositioning, no dragging, head of bed at 30 degrees or lower except at meals. Moisture (3) and sensory perception (3): scheduled toileting before bed and at 02:00 continued; no barrier product indicated; she reports discomfort reliably, so no added surveillance.
Response, reassessment, and communication: E.W. accepts repositioning and toileting. She declined the evening snack on 09/12/2026 and 09/15/2026 (offered, reason given as feeling full, yogurt accepted on 09/15/2026 instead), documented on the intake record. Next scheduled Braden 09/24/2026 (week four), then quarterly with the MDS and with any change of condition; reassess sooner for acute illness, new incontinence, reduced mobility, further weight loss, intake below 50 percent for three consecutive days, or any new skin finding. Care plan revised today: nutrition problem added with the goal of intake at 50 percent or more at two of three meals by 09/30/2026 and weight stable at the 09/24/2026 weigh-in; pressure injury prevention interventions continued as above. Reported at shift handoff and to the skin integrity team meeting on 09/18/2026; MDS coordinator notified for the quarterly assessment.
This sample is fictional and for educational purposes. It does not describe a real patient or record; the ratings, dates, and details are invented to show documentation structure and are not clinical guidance. No subscale descriptors or rating anchors are reproduced.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsUnited States: no LAW names the Braden, and the rules that do exist judge what the score led to. In long-term care, 42 CFR 483.25(b)(1) (LAW, surveyed as F686) requires a facility to ensure that a resident who enters without pressure ulcers does not develop them unless the resident's clinical condition demonstrates they were unavoidable, and that a resident with pressure ulcers receives the care needed to promote healing, prevent infection, and prevent new ones; the interpretive guidance in Appendix PP of the State Operations Manual frames avoidability around four steps (evaluate the resident's condition and risk factors, implement interventions consistent with the resident's needs and professional standards, monitor and evaluate their impact, and revise them), and the CMS pressure ulcer critical element pathway (CMS-20078) sends surveyors to the comprehensive assessment, the pressure relief devices, the repositioning schedule, the scheduled skin inspection, and the care plan, asking whether risk was comprehensively assessed, whether a care plan with interventions and measurable goals followed, whether it was implemented, and whether effectiveness was reassessed and the plan revised (F656 and F657 carry the care plan and revision requirements). The RAI Manual for MDS 3.0 item M0100 (LAW as to the assessment, PAYER POLICY as to its use) offers a formal tool such as the Braden or Norton as one response option beside clinical assessment and states that "the requirements do not mandate the use of any specific assessment tool" other than the RAI itself. In hospitals, Section 5001(c) of the Deficit Reduction Act of 2005 put stage 3 and 4 pressure ulcers among the 14 hospital-acquired condition categories for which Medicare pays no additional amount when the condition was not present on admission, for discharges on or after October 1, 2008 (PAYER POLICY); the present-on-admission indicator has been reported since October 1, 2007; the ICD-10-CM Official Guidelines let a coder take the pressure ulcer stage from documentation by clinicians who are not the patient's provider while the diagnosis must come from the provider; and the determination rests on the admission skin inspection, never on the Braden total, with no coding deadline by which a provider must document present-on-admission status, so early baseline inspection is good practice rather than a coding rule. The separate Hospital-Acquired Condition Reduction Program scores a patient safety composite that includes the pressure ulcer rate (PSI 03). In home health, OASIS collection is required (LAW and PAYER POLICY), but OASIS-D retired the M1300 and M1302 risk-tool items in January 2019 and the current item set records pressure ulcer and injury status, so an agency uses the Braden under its own policy and should not describe it as an OASIS requirement (the OASIS assessment page covers the items that exist). Accreditation and benchmarking are CONVENTION: Joint Commission standards ask accredited organizations to assess and periodically reassess pressure injury risk and act on it, NDNQI and Magnet track hospital-acquired pressure injury as a nurse-sensitive indicator, and none names the Braden or sets its interval. Two habits deserve the same label. "Braden every shift" is a unit policy, not a federal rule; the 1998 validation reassessed at 48 to 72 hours. "Turn every two hours" is a protocol default, not a guideline mandate: the TURN trial (Bergstrom and colleagues, 2013; 942 residents in 27 US and Canadian nursing homes on high-density foam) found pressure ulcer incidence of 2.5, 0.6, and 3.1 percent with 2-, 3-, and 4-hour repositioning (P = .68), TEAM-UP (Yap and colleagues, 2022; 992 residents in nine nursing homes) reported no incident injuries across 2-, 3-, and 4-hour intervals against a 5.24 percent baseline, and the 2026 International Guideline individualizes the interval to the person, the surface, and the skin response while advising against routinely extending it for everyone. In litigation and survey defense (CONVENTION), repeated risk scores with no documented response to the identified risk leave a chart open to the retrospective question of whether the assessment changed care; no published dataset quantifies how often plaintiffs' experts target that pattern, and this page does not claim one.
Canada and Australia require a validated process and name no tool, and the evidence explains why the ratings matter more than the total. In Canada, no federal or provincial statute names the Braden; Accreditation Canada's Required Organizational Practices have included pressure injury prevention with risk assessment on admission and at intervals for the programs they cover, and the current wording should be confirmed in the standards set your organization is surveyed against (CONVENTION with accreditation force); the Registered Nurses' Association of Ontario best practice guideline on the assessment and management of pressure injuries for the interprofessional team (third edition, 2016) and Wounds Canada's best practice recommendations carry the clinical standard, and provincial long-term care and health authority toolkits reproduce the scale under license with the 1988 copyright line of Braden and Bergstrom. In Australia, the NSQHS Comprehensive Care Standard (second edition) requires health services to have pressure injury prevention systems consistent with best-practice guidelines, comprehensive skin inspections within best-practice time frames, and patient information and equipment for prevention (actions 5.21 to 5.23; CONVENTION with accreditation force); pressure injury sits on the ACSQHC hospital-acquired complications list, the National Aged Care Mandatory Quality Indicator Program counts pressure injuries in residential aged care, and the Waterlow score is used alongside the Braden, so the note names which instrument produced the total. On the evidence: the 1987 paper reported inter-rater correlations of .83 to .94 for nurses' aides and licensed practical nurses and .99 for registered nurses, with 100 percent sensitivity at a cutoff of 16 in its two samples; the 1998 multisite study of 843 adults in tertiary hospitals, VA medical centers, and skilled nursing facilities found 18 the best overall cutoff and reassessment at 48 to 72 hours more predictive than the admission score; Bergstrom and Braden (2002) found that 18 performed similarly in Black and White participants (sensitivity and specificity of about 75 and 76 percent against 70 and 77 percent), so the dark-skin problem is one of detecting early injury during the skin inspection, not of adjusting the arithmetic; Huang and colleagues (2021) pooled 60 studies and 49,326 participants to a sensitivity of 0.78, a specificity of 0.72, and an area under the curve of 0.82 with 18 as the optimal cutoff, calling the predictive validity moderate; Mehicic, Burston, and Fulbrook (2024) found inconsistent psychometrics across 34 intensive care studies, total-score intraclass correlations of 0.66 to 0.96, and most ICU cutoffs in the range of 12 to 14; Pancorbo-Hidalgo and colleagues (2006) found the Braden the best-validated scale across 33 studies (sensitivity 57.1 percent, specificity 67.5 percent, odds ratio 4.08); and Moore and Patton's Cochrane review (2019) found two trials with 1,487 participants and evidence too uncertain to show that structured risk tools reduce pressure ulcer incidence compared with clinical judgment. In pediatrics, the Braden Q was validated in 322 children on bed rest from about three weeks to eight years of age, the Braden QD in 625 patients from preterm infants through age 21 at eight centers with an area under the curve of 0.78, and the Braden QD's total runs in the opposite direction (higher meaning more risk), so a pediatric note names the instrument and version before the number. On versions: the licensor describes the Braden Scale II (2022) as keeping the six subscales with updated terminology and descriptors, and an institution's rights under an older implementation are not automatically the same as a current Braden Scale II license, so the record names the version, and an electronic build carries the licensor's authorization for the provider rather than an assumption that the vendor cleared it.
The Braden Scale for Predicting Pressure Sore Risk is a copyrighted instrument: it was published by Bergstrom, Braden, Laguzza, and Holman in Nursing Research in 1987, and authorized copies carry the copyright line of Barbara Braden and Nancy Bergstrom, 1988, with the instrument's full name and no changes to wording or scoring. Prevention Plus, the company the authors founded to license it, was acquired on April 20, 2021 by Health Sense Ai, a subsidiary of HD Nursing, which announced that it would be the sole licensor of the Braden Scale going forward and now describes itself as the owner of the Braden Scale and Braden Scale II copyrights; permission to use the Braden Scale II (2022) is granted only through a Health Sense Ai license agreement sold by care setting, the public pages publish no blanket free-use grant for websites, calculators, forms, or electronic builds of the adult scale, and a 2023 Advances in Skin and Wound Care piece (Delmore and Ayello) reported the licensor's position that facilities already using the original scale could continue for the time being and that licensing runs to providers rather than to record vendors. No enforcement action was found in either research pass, which is a null finding and not a permission. The Braden Q and Braden QD are copyrighted by Martha A. Q. Curley (Braden QD, 2018), who permits unmodified reproduction for research and clinical practice, including hospital forms and hospital-based electronic records, and requires written permission for commercial use, external republication, and translation. BastionGPT is not affiliated with, or endorsed by, any of these publishers. This page reproduces no test items, stimuli, norms, or scoring materials.
The numbers behind these errors are specific. In two nursing homes, trained raters' totals for the same residents differed by up to nine points, with intraclass correlations of 0.73 to 0.95 for the total and far lower for sensory perception and nutrition, and years of experience made no difference (Kottner and Dassen, 2008); after web-based training, 1,391 registered nurses at three medical centers classified risk level correctly 82.6 percent of the time and struggled most in the middle of the range (Magnan and Maklebust, 2008); a 2024 review of 34 intensive care studies found total-score reliability of 0.66 to 0.96 and most empirically derived ICU cutoffs at 12 to 14 rather than 18 (Mehicic, Burston, and Fulbrook); the 1998 multisite validation found reassessment at 48 to 72 hours more predictive than the admission score (Bergstrom and colleagues); the TURN trial found no difference in pressure ulcer incidence among 2-, 3-, and 4-hour repositioning of at-risk residents on high-density foam (2.5, 0.6, and 3.1 percent, P = .68; Bergstrom and colleagues, 2013); and the Cochrane review found only two trials, 1,487 participants, and no reliable evidence that a structured tool lowers incidence compared with clinical judgment (Moore and Patton, 2019). No published audit counts how often a chart carries a Braden total with no linked intervention; the F686 survey pathway and the hospital-acquired condition and present-on-admission rules described under compliance considerations are what turn that omission into a deficiency or a payment problem. The BastionGPT Clinical Advisory Board sees the same errors most often in Braden Scale documentation reviews:
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The Braden Scale rates six subscales, named here by their published labels with the intent of each in original words: sensory perception (whether the patient can notice pressure discomfort and act on it or call for help), moisture (how wet the skin stays through the day), activity (how much the patient is up and about), mobility (how well the patient repositions without help), nutrition (how well the patient is actually eating), and friction and shear (how much the skin drags against surfaces during movement and transfers). Five subscales are scored 1 to 4 and friction and shear 1 to 3, the total runs from 6 to 23, and a lower total means higher risk. The descriptors that define each rating are the copyrighted text of the instrument, so this page does not reproduce or paraphrase them; rate from the licensed form your organization uses and write the basis for a low rating in ordinary clinical words. The total is a risk signal: a low rating on any one subscale calls for its own preventive measure, which is why the six ratings, not just the total, belong in the record.
It depends on the population and the protocol, which is why the note cites the protocol. The original 1987 validation set its cutoff at 16, where sensitivity was 100 percent in both study samples. The 1998 multisite study of 843 adults in tertiary hospitals, VA medical centers, and skilled nursing facilities found 18 the best overall cutoff, and Bergstrom and Braden confirmed 18 in Black and White participants in 2002; Huang and colleagues' 2021 meta-analysis of 60 studies also landed on 18 with only moderate predictive validity (sensitivity 0.78, specificity 0.72). In intensive care, a 2024 systematic review found most empirically derived cutoffs at 12 to 14, because sedation, ventilation, and vasopressors cluster nearly every ICU patient below 18. The graded categories most facilities use come from the authors' later recommendations and live in facility protocols, not in the 1987 instrument. Document the total, the facility category, and the protocol that defines it, and never present a cutoff as a physiologic law or as a rule that by itself prescribes a surface or a turning interval.
No regulator sets a Braden interval, and CMS does not require the Braden at all: 42 CFR 483.25(b) requires assessment, prevention, monitoring, and revision, the RAI Manual states that the requirements do not mandate any specific assessment tool, and F686 guidance names validated tools as examples. "Every shift" in acute care and "weekly for four weeks, then quarterly and with change of condition" in long-term care are facility conventions, and the 1998 multisite validation itself reassessed at 48 to 72 hours after admission, where prediction improved. What the evidence and the guidelines do support is reassessment on admission, on transfer, when the clinical picture changes (new sedation or immobility, surgery, incontinence, falling intake, fever, hemodynamic decline), at transitions of care, and before discharge. Follow your policy, cite it in the note, and name the trigger for every repeat, because a dated trigger is what distinguishes monitoring from a repeated number; and never carry ratings forward without re-observing the patient.
No. The Braden predicts the risk of a future injury; it does not examine the skin, and a low total says nothing about whether an injury already exists. Chart a separate visual and tactile inspection of the pressure points and every device contact site, with findings by location and laterality, and for darker skin tones compare with the person's usual tone and palpate for warmth, firmness, and tenderness rather than relying on redness. If an injury is found, it is described and staged under the conventions on the pressure injury staging page, and the provider documents the diagnosis; the ICD-10-CM guidelines let a coder take the stage from nursing documentation but the diagnosis only from the provider, so the two must agree. Present-on-admission status for the hospital-acquired condition rules rests on that admission inspection, never on the Braden total, and CMS sets no coding deadline for documenting it, so the baseline inspection is good practice and evidence rather than a payment rule.
Treat the low subscale as the finding. The authors, the Hartford Institute for Geriatric Nursing, and the international guideline bodies all say that low subscale ratings should drive prevention regardless of the total, because the total is an aggregate that can mask a single actionable problem. A patient whose only low rating is moisture needs the cause managed, a cleansing and barrier regimen, and a continence or microclimate plan today, not when unrelated subscales deteriorate enough to pull the total down; a patient whose only low rating is nutrition needs intake monitoring, weights, and a dietitian referral, without the rating being equated with malnutrition. Write the six ratings, name the low one and its basis in clinical words, record the measure started and how it is delivered, and set the reassessment. An entry that reads, in effect, total above the facility threshold, moisture rating identifies actionable risk, moisture management started, reassess on the stated date, is exactly what a surveyor or reviewer wants to find.
For a refusal, chart the offer, the patient's stated reason where appropriate, the education given about the risk, the alternatives offered or accepted (a smaller shift, a different position, a change of surface or cushion, a later time), who was notified under policy, and the revised plan. Do not record care that was not delivered, and do not leave the word refused standing alone. The 2026 International Guideline builds comfort and preference into repositioning decisions, including at the end of life, and survey and serious-event frameworks recognize refusal and clinical instability as circumstances that require documentation when preventability is judged. The rating does not change because a measure was declined; the feasibility of the plan does, so the plan is what you revise. For the mattress: a new surface is an intervention, not one of the six subscales, so the total should improve only if the patient's own condition improved (better intake, more independent movement, resolved incontinence). Write which rating changed and why in clinical terms, keep the surface in place, continue the inspections that show whether the surface is working, and never discontinue a prevention measure because the number rose.
Use the instrument your organization has adopted for the population in which it was validated, and name it in the note. The Braden Q (Curley, Razmus, Roberts, and Wypij, Nursing Research, 2003) adapted the adult framework for children, added a tissue perfusion and oxygenation subscale, and was validated in 322 children on bed rest from about three weeks to eight years of age, so it is not evidence for a 15-year-old. The Braden QD (Curley and colleagues, Journal of Pediatrics, 2018) was validated in 625 patients from preterm infants through age 21 at eight centers, was built to predict both immobility-related and medical-device-related injury, and scores in the opposite direction from the adult scale and the Braden Q: a higher Braden QD total means more risk. Three consequences for the chart: the instrument and version come before the number, a Braden QD total cannot be trended against a Braden Q or adult total, and device-site inspection is part of the pediatric entry. The Braden Q and QD are copyrighted by Martha A. Q. Curley, whose published permission allows unmodified clinical and research use, including hospital forms and hospital-based electronic records, with written permission required for commercial use, external republication, and translation.
Only with the rights holder's permission. The Braden Scale is copyrighted (Barbara Braden and Nancy Bergstrom, 1988), and since April 20, 2021 its licensing has been administered by Health Sense Ai, a subsidiary of HD Nursing, which acquired Prevention Plus, announced itself as the sole licensor, and describes itself as the owner of the Braden Scale and Braden Scale II copyrights. Its public pages say that permission to use the Braden Scale II is granted only through a Health Sense Ai license agreement, sold by care setting, and they publish no blanket grant for websites, calculators, custom forms, or electronic builds of the adult scale; a 2023 Advances in Skin and Wound Care piece reported the licensor's position that facilities already using the original scale could continue for the time being and that licensing runs to the provider rather than to the record vendor, so an EHR build should rest on the facility's own authorization rather than an assumption that the vendor cleared it. The fact that the anchored form appears on educational and calculator sites is not permission, and neither is being free or non-commercial. What needs no license is the concept: numeric fields for six ratings and a total, your own documentation prompts in original words, and the structure on this page. The Braden QD has a different and more permissive published permission from its own rights holder.
Yes. Give it the facts (the trigger and version, the six ratings and total with the prior totals, the basis for the low ratings, the facility category and protocol, the skin and device-site findings, the measures in place or started for each low rating, the patient's response, the notifications, and the next reassessment) and it drafts the full entry: trigger and version, ratings and total, category attributed to policy, separate inspection, an intervention for each low subscale, response, and the reassessment and communication lines, ready for your review. It can also check a finished entry for a total with no ratings, ratings copied forward, a category written as the scale's rule, the score standing in for the skin inspection, a bundle with no subscale behind it, a refusal with no context, or a missing reassessment date. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
The instrument facts and compliance claims on this page trace to these sources, last verified September 2026:
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.