Q: What should be included in the note for periodic review of restorative nursing programs?
A: As the nurse overseeing restorative nursing, when reviewing restorative documentation, ensure the note answers these questions:
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- Was the restorative intervention actually performed?
- Did it match the care plan and physician order?
- How much assistance was required?
- How did the resident respond to/tolerate the restorative intervention?
- Is the resident maintaining or improving function?
- Is there evidence the program remains appropriate, or does it need modification?
- Is there any change in condition that requires assessment, therapy referral, or care plan update?
Strong restorative notes are objective, measurable, and individualized. They support regulatory compliance while clearly showing how restorative nursing is helping the resident maintain or improve functional abilities.
Examples of Restorative Nursing Notes
Mary participated in restorative ambulation program as scheduled. No refusals were noted during the 30-day look back. She ambulated 150 feet with front-wheeled walker and contact guard assistance. She demonstrated steady gait with occasional verbal cues to maintain upright posture and for walker placement. She tolerated ambulation activities without complaints of pain or shortness of breath. No loss of balance observed. Resident was cooperative and motivated throughout the session. She continues to maintain current mobility level and is maintaining restorative goals of ambulating 150 feet. Plan to continue current program and monitor for changes in endurance or functional status.
Steve has Active Assistive Range of Motion (AAROM) program in place. He demonstrates increased cognitive impairment, resulting in an inability to consistently understand or follow verbal instructions required to actively participate in AAROM exercises. Frequent cueing and demonstration have been ineffective in achieving consistent active participation. He is no longer meeting the established goal for the AAROM program due to impaired cognition. To maintain joint mobility, minimize the risk of contractures, and support comfort, the restorative program will be changed from Active Assistive Range of Motion (AAROM) to Passive Range of Motion (PROM). PROM is more appropriate to meet the resident’s current needs and abilities.
Next Steps:
Register to Join Proactive on August 5, 2026 for the virtual workshop Restorative Nursing Excellence: Revitalizing Programs and Restoring Function. This full day training provides a valuable refresh to advance Restorative Nursing Programs and provides practical guidance to overcome common barriers to Restorative Program success.
Reference:
Centers for Medicare & Medicaid Services (CMS). Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) User’s Manual, Version 1.20.1. Effective October 1, 2025. Available at:
CMS MDS 3.0 Resident Assessment Instrument (RAI) Manual
Written By:
Brandy Hayes, RN, RAC-CT, RAC-CTA
Clinical Consultant
Proactive LTC Consulting
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