Form 3643
Instructions

Nursing Restorative Care Program

01-1997

PURPOSE

Form 3643 is used to document restorative nursing (TILE 202) requirements.

PROCEDURE

Complete Form 3643 for each resident at the initiation of restorative nursing care and at the first of each calendar month.

Discipline

Check the therapy discipline on whose written plan of care the restorative program is based.

Month

Enter the current calendar month in which restorative services are to be provided.

Year

Enter the year in which restorative services are to be provided.

SECTION I — PLAN OF CARE

Date Restorative Initiated

Enter the date of the first restorative visit. Include month, date, and year.

Goal

List the restorative nursing program goals based on the therapist's written plan of care and developed by the restorative team which included the therapist and a registered nurse.

Plan

List the restorative nursing treatment approaches. Include the per day frequency and the number of days per week that the resident is to receive restorative care based on the therapist's written plan of care. The written plan of care must be developed by the restorative team consisting of a therapist and a registered nurse.

Signatures

This section requires "RN" and "therapist" signatures.

SECTION II — APPROACHES

Approaches #1-5

The numbered approaches correspond to the same numbered approaches listed in Section I.

Grid

Following each restorative nursing treatment session, the restorative aide or nurse aide trained to deliver restorative care initials the row corresponding to the treatment approach provided and in the column corresponding to the date the service was provided.

If the restorative session or approach is withheld or refused, use the following codes:

W = Withheld
R = Refused

Enter the codes under the appropriate date column and document the reason in the weekly note.

Initials and Signature

Enter the initials and signature of each restorative nurse aide or nurse aide trained to deliver restorative care or licensed nurse completing Section II of the Nursing Restorative Care Program Form.

BOTTOM OF FIRST PAGE

Resident

Enter name of resident receiving restorative care (last name first).

Room

Enter room number of resident receiving restorative care.

SECTION III — RESIDENT'S RESPONSE AND PROGRESS TOWARD GOAL(S)

Resident's Response

Weekly, the restorative aide or nurse aide trained to deliver the restorative care should write a note about the resident's response to the nursing restorative care program. An option is that a licensed nurse or therapist can complete the weekly note of the resident's response to the program. The individual writing the weekly response must sign the note.

Note: A treatment/approach that is withheld or refused should be noted in the weekly response note. If the resident receives more than one treatment of an approach per day, comments on the frequency should be noted in the weekly response note.

SECTION IV — MONTHLY REVIEW

Monthly Review

The licensed staff (nursing and/or therapy) is to review the appropriateness of the Nursing Restorative Care Program by answering all of the questions in this section.

If restorative care is continued to the next month, rewrite the plan of care in Section I on the new form for the next month. This should include any recommended changes noted from Section IV. The date restorative care was initiated does not change on the new form.

Note: If approaches are changed, added, or deleted during the month, amend the form in the following way:

  1. Section I: Document the change under the approaches and the new effective date.
  2. Section III: Comment on the change, addition, or deletion for the week that the change occurred.