Body Map Form

What is a body map?

A body map is a front and back outline of a person's body. Care staff mark on it where they found a bruise, cut, skin tear, burn, rash or patch of pressure damage, then describe each mark in writing. The outline and the notes together give the manager, the GP and any safeguarding team the same picture of what staff saw and when they saw it.

This body map template works for adults in care homes, home care and supported living.

What the form includes

• Person and form details, including whether the person agreed to the check

• Front and back outlines, with each body area named so a mark number goes in the right place

• A marks table for type, size in centimetres, colour and what the person said

• Reporting questions: first aid, GP or 111, safeguarding referral, CQC notification, police and family

• Checks on healing in the days that follow

• Sign-off by the staff member and the Registered Manager

How to fill in a body map

1. Ask the person's consent before you look. If they lack capacity for this decision, follow the Mental Capacity Act 2005 and note where that decision is recorded.

2. Look only at what you need to see. Right and left always mean the person's own right and left.

3. Give each mark a number, draw it on the outline, and write the same number in the matching body area.

4. Describe what you see, not what you think caused it, and write down what the person says in their own words.

5. Tell the Registered Manager straight away.

Use one form for each date you find new marks, and fill it in during the same shift or visit. Staff never decide on their own whether a mark is abuse: that call belongs to the manager, and the form sets out the tests they use.

When a mark needs reporting

CQC must hear without delay about any abuse or allegation of abuse, and about injuries that meet the serious injury tests in regulation 18. CQC's own examples include a pressure sore of grade 3 or above that developed after the person started using your service. Pressure damage caused by poor care can also be a safeguarding concern, so it needs a clinical response and a safeguarding one.

If the mark came from a fall or accident, log it in the Accident & Incident Log under the same reference. Suspected abuse follows your Safeguarding Policy & Procedure, and residents who fall often need a Falls Risk Assessment.

Before you use it, add your local authority's adult safeguarding number, your out-of-hours manager contact and your own rule on photographs of marks.