The Braden Scale rates six areas, from sensory perception to friction and shear, to predict how likely a patient is to develop a pressure injury. Totals run from 6 to 23, and a lower score means a higher risk. See what each risk level means and which prevention steps follow, then record the result with the free template.
Braden Scale result template
FreeBRADEN SCALE RESULT Date and time: [Date, time] Patient: [Name or ID, age] Setting: [Hospital unit, long-term care, or home visit] Reason: [Admission, shift or scheduled reassessment, change in condition, transfer, or discharge] Version: [Braden Scale or Braden Scale II, from the facility's licensed form] Scored by: [Name, credentials] SCORES Sensory perception: [1 to 4] Moisture: [1 to 4] Activity: [1 to 4] Mobility: [1 to 4] Nutrition: [1 to 4] Friction and shear: [1 to 3] Total: [6 to 23] Risk level: [Very high, high, moderate, mild, or no added risk] Other risk factors: [Advanced age, fever, poor protein intake, low blood pressure, unstable condition, medical devices, or none] TREND Previous scores: [Dates and totals] Change: [Better, worse, or the same, and why] SKIN INSPECTION Areas checked: [Sacrum, coccyx, heels, hips, elbows, back of the head, ears, and skin under devices] Findings: [Intact, or redness that blanches or doesn't, with site and size] Pressure injury: [Stage, site, and size for each, or none] Devices: [Tubes, masks, splints, casts, or stockings, and the skin under them] PREVENTION PLAN Repositioning: [Turning schedule, positions, and who helps] Support surface: [Mattress or seat cushion type, or standard] Heels: [Floated with pillows or boots, or not needed] Moisture: [Continence care, barrier cream, and pads] Nutrition: [Intake, weight, dietitian referral, and supplements] Friction and shear: [Head of bed angle, lift sheet, and transfer aids] Teaching: [What the patient or family was taught, and what they understood] NEXT ASSESSMENT Reassess: [Next shift, date, or the interval the setting requires] Reported to: [Charge nurse, provider, wound care nurse, or dietitian, and when] Signed: [Name, credentials, date and time]
Use it for
A nurse scores it from what they see at the bedside, the chart, and talking with the patient, the family, and the care team, on the facility’s licensed form.
Avoid: Copying the last score forward. The Braden changes as the patient changes, and a stale score hides new risk.
Six subscales: five scored 1 to 4, and friction and shear scored 1 to 3, added for a total from 6 to 23.
Avoid: Reading a healthy total as safe when one subscale is 1. A single very low subscale still needs its own prevention step.
A lower total means a higher risk, and 18 or below calls for a prevention plan.
Avoid: Treating the number as the whole assessment. It predicts risk; it doesn’t find a pressure injury that is already there.
Check the skin over every bony prominence and under every device at the same time as the score.
Avoid: Writing “skin intact” without saying which areas you checked.
The plan follows the total and the low subscales, and it goes in the same note as the score.
Avoid: A score with no plan beside it. The plan is the reason for scoring.
Score again at the interval the setting requires, and whenever the patient’s condition changes.
Each one follows the recording template. Use them to judge how much to write.
Medical unit, admission assessment, evening shift
84-year-old woman admitted from home with pneumonia. Sensory perception 3, moisture 3, activity 1, mobility 2, nutrition 1, friction and shear 2. Total 12, high risk. Other risk factors: age 84, and a fever of 38.4 °C (101.1 °F) on admission, so the unit protocol manages her one level up, as very high risk.
First score this admission. Scored 19 at a home care visit in August.
Sacrum, coccyx, hips, elbows, and back of the head intact. Redness over both heels that blanches on pressure. Early redness behind both ears from the oxygen tubing; foam padding added. No pressure injury.
Mobility and activity: in bed since admission and turns only with help, so turns every 2 hours, alternating 30-degree side-lying positions, and a pressure-redistributing mattress ordered. Heels floated on pillows. Nutrition: eating under a quarter of each meal for 4 days, and down 3 kg (7 lb) in a month; dietitian referral today, a protein supplement twice daily, and intake charted. Head of the bed at 30 degrees or lower except at meals. Daughter shown how to help with turns.
Every shift, and sooner if her breathing or eating changes. Reported to the charge nurse and the admitting physician at 20:30.
Orthopedic unit, day 4 after a right total hip replacement
67-year-old man. Sensory perception 4, moisture 4, activity 3, mobility 3, nutrition 3, friction and shear 3. Total 20, no added risk. Other risk factors: none; no fever, blood pressure stable.
Day 1: 16, mild risk, in bed after spinal anesthesia, drowsy on opioids, and turning only with help. Day 2: 17. Day 3: 18. Day 4: 20, walking to the bathroom with a walker and eating most of each meal.
Sacrum, heels, and hips intact, with no redness. Hip dressing dry. Skin under the compression stockings intact.
Day 1 to 3: turns every 2 hours with a pillow between the knees, heels floated, and the head of the bed kept low. Today the turning schedule and heel pillows stop, as he now changes position on his own. Keeps walking with physical therapy three times a day. Usual skin care.
Every shift until discharge home, planned for tomorrow. Score again sooner if he stops walking or develops a fever.
A score carried over from the last shift misses the patient who has since had surgery, been sedated, or stopped eating. Score the patient in front of you.
A total of 13 with no prevention steps beside it leaves the risk where it was. Write the plan in the same note as the score.
A total of 17 can include a nutrition score of 1. Each low subscale needs its own step, whatever the total.
The Braden predicts risk. It won’t find early damage on a heel; only looking at and feeling the skin will.
Its top score is 3, so the highest total is 23, not 24.
Vero Scribe records the Braden result in your template from the visit, with the patient’s consent, or from your dictation: the subscale scores, the skin findings, and the prevention plan that follows. You review and edit every line, then copy it into your record. Vero works in 60+ languages.
Score each of the six subscales: sensory perception, moisture, activity, mobility, and nutrition from 1 to 4, and friction and shear from 1 to 3. Add them for a total from 6 to 23. The official form and scoring guide describe what each score means.
A lower total means a higher risk of a pressure injury. The usual risk levels are 19 to 23 no added risk, 15 to 18 mild risk, 13 to 14 moderate risk, 10 to 12 high risk, and 9 or below very high risk.
The scale’s owners give 18 or below as the at-risk cutoff, based on a 1998 multisite study by Bergstrom and colleagues. Older sources use 16, or 15 to 16, and keep 18 for older adults. Follow your facility’s protocol.
On admission, then as often as your setting requires. The scale’s owners suggest every shift and with any change in condition in hospital; on admission and weekly in long-term care, moving to monthly after the first month for long-stay residents; and at each nurse visit in home care.
Both predict pressure injury risk, and on both a lower score means a higher risk. The Norton Scale has five items, physical condition, mental condition, activity, mobility, and incontinence, scored 5 to 20. The Braden adds nutrition and friction and shear, and it’s the one most often used in North America. The Waterlow scale works the other way: a higher score means a higher risk.
An update of the original scale, released in 2022 by Health Sense Ai. Dr. Amy Hester developed it with Drs. Barbara Braden and Nancy Bergstrom. It modernizes the wording and clarifies the scoring of the same six subscales, and it comes with a scoring guide and a training module under license.
Nurses usually score it, on admission and at each reassessment. Your facility’s policy sets who may score it. The training that comes with the license helps different nurses give the same patient the same score.
No. The Braden Scale and Braden Scale II are copyrighted by Health Sense Ai, and organizations use them under a license set by care setting. Get the official form through your facility’s license or the Braden Scale site. The recording template on this page is free to copy or download.
It was developed and tested in adults. For children, there is a pediatric version, the Braden Q.
For a pressure injury that is already there: stage, size, wound bed, and dressing plan.
The full nursing assessment, with the Braden score in the skin section.
Nursing progress notes, DAR examples, and SBAR drafts.
Every tool, by area, with what its scores mean.
Vero records scores, findings, and plans in the templates you choose, so you review instead of type.
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