5.07 Documentation

Evaluation.

Evaluate the patient in terms of fatigue, joint discomfort, and joint mobility.

Record Keeping.

Range of motion is often placed on a flow sheet (see figure 5-3).

If a flow sheet is not used, an entry should be made in the Nursing Progress Notes using a narrative format. If there is any adverse response to the exercises, a narrative note must be made. Nursing notes should address the extent to which joints can be moved in degrees (see figure 5-4).

Figure 5-4. Example of Narrative Note.
Figure 5-4. Example of Narrative Note.

Basic Nursing Education