Question
What is the proper way to document the Restorative Nursing Program? Is it put in the Medical Record, and should the Restorative Staff keep track of its completion?
Is a doctor's order needed for the Restorative Program?
Answer
The Restorative Nursing Programs are required - it is a Federal Regulation - that they do daily documentation in terms of a billing grid. Since each program has to be done 6 days a week minimum, many facilities just provide staffing 7 days a week in case there is a refusal. We have them fill out the log to show that the program was provided. They have to enter minutes spent on the program and enter their initials confirming that they were the ones to provide the program. All of that is kept with the Medical Record. The actual program itself can be kept in the Medical Record if you write it as a Plan of Care - a Care Plan. Many times they are kept it in a separate Restorative binder so that it is clear exactly which program it is. Other times, it is kept in the Restorative Nursing part of the Medical Record; the hard chart may have a section just for Restorative. The original may be kept there, and then a copy gets kept in the binder. It's all Federally regulated, so that's a process that has to be put into place.
On a monthly basis, your RN or LPN (whoever is in charge of overseeing the program) has to do a quick note. It can be as simple as "Patient is doing great. Continue with plan of care." That is all that they have to sign off on as long as they have a narrative note at least once a month. Some facilities also require that a restorative aid also do some documentation if there has been a refusal. That is not part of the Federal Regulation, it is just a policy that your building may or may not have.
From a regulation standpoint, you are not required to have a doctor's order. However, if you have an issue with accountability and things being followed through with, I recommend doing a doctor's order because you are then very likely to have those programs followed especially with splinting and some of the more serious programs. Getting a doctor's order may be a policy your facility follows or a general recommendation.
