Restorative Nursing Documentation

Restorative NursingDocumentation Provide guidelines for completingrestorative documentationAssist facilities with supportivedocumentationReview MDS terminology for documentationon daily flow sheetProvide a record of treatmentEstablish standards of care Act as a daily communication tool Basis for evaluating care 1

Program/area(s) treated Procedures to be performed Duration/repetitions Frequency and duration Resident-specific strategies Goals for each program Daily Documentation Remember - if it is not documented – It isnot done Specific restorative nursing interventions Daily flow sheet Weekly Notes Describe ability to perform activities Compare to goals Determine if progress is madeNumber of times resident was seenAny gains made Any unusual occurrences Response to treatment Strategies addressed in treatment For example, extremities ranged, distancewalked, ADL status, percent eaten2

Daily note required Time spent per program must bedocumented Neat and legible Compare progress Reason for missed or refused session Try to make up minutes Document IDT communication Ambulation Length/distance walked Assistance needed Weight bearing precautions Assistive devises used Range of Motion Joint(s) ranged Type of range (PROM, AROM, AAROM) Number of repetitions Amount of movement Application of splint Positioning3

Restorative Dining Amount eaten Assistance needed Assistive devices used Precautions for safety in swallowing Thickened liquids Positioning Compensatory techniques Activities of Daily Living Progress toward stated goals Assistance needed Assistive devices Compensatory strategies used Continence Goal Assistance needed Adaptive equipment used Voiding/bladder training schedule Number/frequency of incontinentepisodes Toileting program Medications impacting continence4

Toileting Programs Bladder Retraining Prompted Voiding Habit Training/Scheduled Voiding Check and Change Communication Difficulty expressing wants and needs Difficulty following simple instructions Difficulty understanding Y/N questions Slurred speech Difficulty naming or using common ADLobjects Difficulty following conversation Swallowing Doesn’t swallow all food Coughs during meals Recent weight loss Altered diet Compensatory swallow strategies Difficulty accepting oral intake Difficulty or prolonged chewing Pocketing5

Ambulation Can ambulate only short distances Difficulty with transfers Poor balance Limited UE/LE function Leans when ambulating Impaired ambulation due to injury Learning to use assistive device forambulation Range of Motion Impaired extremity use due to CVA Developing hand contractures Foot drop Edema in arms or legs Needs to be taught self-repositioning Self-feeding Tires easily at mealtime; eats slowlyNeeds encouragement or cuesRecent removal of feeding tubeRecent weight lossNeeds socialization at mealtimeReminders to eatDoes not finish mealsDecreased attention to eating taskDifficulty recognizing food and/or utensilsLearning to use adaptive equipment6

Activities of Daily Living Tires easily during morning routine Task segmentation Needs encouragement and/or cues Poor balance Limited use of upper extremities Easily distracted Learning compensatory strategies fordeficits in self-care Need to use adaptive equipment for ADL Continence versus incontinence Urge to urinate but cannot make it to therestroom Frequent urination Leaks while laughing, coughing, sneezing Frequent episodes of urinary incontinence Slow to make it to the restroomPerforming activity at independentlevel Performing activity under nursingsupervision Further improvement not anticipated Regression has occurred Nursing and/or Therapy should beconsulted7

Start of care Type of services received Goal(s) Performance at the start of care and atdischarge Length of treatment Reason for discharge Follow up to be provided Remember if it is not documented, it is notdoneDon’t save it until the end of the dayDocument during/soon after session whenthe information is fresh in your mindDo not complete all weekly summaries onone dayIf daily notes are complete, weekend staffcan assist with weekly notesAccurately record and documentfunction ID techniques and strategies used bynursing Augments other documentation andcommunication tools Completed every shift 8

Bladder and bowel function Skin care Pattern of continence during shift Specific/generic skin treatments receivedduring shift Shower/shampoo givenMood/behavior patterns Any indicators of depression, anxiety orsad mood expressed during shift Percentage of meals eatenBedrail/side rail position Range of motion Indicate reason for use Indicate active or passive Splint or brace application Include specific schedule or instructionsTraining and skill practice Bed mobilityTransferWalkingDressing orgroomingEating orswallowingAmputation/prosthesis care tOstomy careCardiacrehabilitation9

Indicate self-performance and support Bed mobilityTransferWalk in roomWalk in corridorLocomotion on unitLocomotion off unit DressingEatingToilet usePersonal hygieneBathingConsider each episode of the activityduring the look-back period Identify what the resident actuallydoes for himself or herself Note when and what type ofassistance is received Code based on level of assistancewhen using adaptive equipment Self-performance may vary from day to day, shiftto shift, or within shiftsCapture the total picture of the resident’s selfperformanceSelf-performance coding options are intended toreflect real world situations where slight variationsin self-performance are commonIt is necessary to know whether an activity occurredthree or more times within the look-back periodIt is recommended that self-performance is scoredbefore support10

If an activity occurs 3 times at one given level,code that levelIf an activity occurs 3 times at multiple levels,code the most dependentIf an activity occurs at various levels, but not 3times at any one level, apply the following: When there is a combination of full staff performanceand extensive assistance, code extensive assistance When there is a combination of full staff performance,weight-bearing assistance and/or non-weightbearing assistance, code limited assistance If none of the above are met, code supervision.Code for performance over all shifts –not including set up Coding total dependence requires fullstaff performance every time CodeMDSCodeDefinitionActivity did not occur8Activity was not performed by residentor staff over 7 day periodActivity occurred onlyonce or twice7Activity occurred only once or twiceTotal dependence4Full staff performance every time duringentire 7-day periodExtensive Assistance3Resident involved in activity; staffprovide weight-bearing supportLimited Assistance2Resident highly involved in activity; staffprovided guided maneuvering of limbsor other non-weight-bearing assistanceSupervision1Oversight, encouragement or cueingIndependent0No help or staff oversight11

CodeDefinition8Activity did not occur: the resident was not bathedduring the look-back period4Total dependence: the resident is unable to participatein the bathing activity3Physical help in part of bathing activity: the residentrequired assistance with some aspect of bathing2Physical help limited to transfer only: the residentperforms the bathing activity, with help only for transfer1Supervision: the resident required oversight0Independent: the resident required no helpCode for the most support providedover all shifts Code regardless of resident’s selfperformance classification CodeADL activity itself did not occur duringentire periodMDS Code8Two persons physical assist3One person physical assist2Setup help only1No setup or physical help from staff012

Ensure all staff use the same terminologyReview documentation and paint a completepicture of resident abilitySome residents sleep on furniture other than a bed– consider this when scoring bed mobilityDo NOT record potential to perform ADLDo NOT record level of assistance the resident“should” receive according to the care planDo NOT include assistance provided byfamily/visitorsMust support services provided to theresident Reflect coordination between nursingand rehab Can impact a claim if reviewed Avoid subjective terms and conflictsrehab documentation Assistance requiredSafety awarenessAdaptive equipmentCognitive issuesFunctional activitytolerance oningPain13

Custodial care Maintaining Intermittent care/service Out of facility on pass Poor or fair rehab potential Inability to follow directions Refused to participate Chronic conditionNot motivated Extreme depression Little change Status quo Plateau Ambulating “ad lib” Vital signs as per facility policyDocumentation in Nurses Notesregarding Restorative services Daily Flow Sheet correspondingservices delivered Documentation in care plan withservices provided, goals andapproaches 14

Documentation to specific functionalstatus on a daily basis Resident response to interventions Progress being made toward goals Periodic evaluation of goals Still room for improvement? Education and training completed toresident and IDTExpress desire but cannot participate?More effort to complete grooming? Assistive devices used? Gestures, verbal/visual cues needed? Obtain or use supplies to shave? Apply and/or remove cosmetics? Wash, comb, style or brush hair? Complete nail care? Skin care? Apply deodorant? Express desire but cannot participate?More effort to complete dressing? Assistive devices used? Gestures, verbal/visual cues needed? Select appropriate clothing? Dress and undress sequentially? Fasten and adjust clothing and shoes? Don/doff adaptive equipment? 15

Performing in bed vs. sink? Noticeable odors present even thoughresident performs hygiene? Cues or gestures needed? Obtain or use supplies? Clean mouth and teeth? Remove, clean and reinsert dentures? More staff to perform bath?Take longer yet still not cleaning self?Exhibit frustration?Assistive devices used?Gestures or cues needed?Are there safety concerns?Obtain and use supplies?Soap, rinse and dry all body parts?Maintain bathing position?Transfer to and from bathing position?Assistance due to balance orsequencing issues? As clean as usual? Good judgment used? Obtain and use supplies? Clean self? Maintain toileting position? Transfer to and from bedpan, toiletand/or commode? 16

Cues or gestures needed?Food getting into mouth? Coughing? Wey/gurgly voice? Can the resident sit up straight to eat? Is an altered diet consumed? Any pocketing? Set up food? Use utensils? Bring food or drink to mouth? Suck, masticate (chew) and swallow? Can a listener understand theresident’s words? Gestures? Any change from normal? Devices or equipment used? Make wants and needs known? Follow directions? Is the resident oriented? Assistance needed to sit up in bed?Roll? Scoot? How many people? Assistance more or less than usual? Any loss of balance? Safety concerns? Assistive devices used? 17

How many people? Assistance? Fall risk? Assistive devices needed? How far can the resident walk? Is thismore or less than usual? Is assistance needed more or less thanusual? Safety concerns? Less comfortable than before?Leaning? Sliding? Falling? Safety concerns? Joints tighter than usual?ROM less than normal? Do splints fit? Resident ate in dining room at lunchResident consumed 50% of food atlunch in dining room. Noted difficulty with feeding self, ( ) tremors5418

Dressed and bathed resident atbedside, no c/o Resident requires limited assist w/upper body dressing & bathing atbedside; requires extensive assist withlower body 55Resident walked to BINGO thisafternoon; holds onto railings Resident ambulated holding ontorailing to BINGO; more unsteadinessnoted 56Resident falling forward out of w/c;c/o back pain Noted leaning forward in w/c,unable to maintain upright posturew/o assist. Rated back pain 6/10 insitting. 5719