Restorative Skills Documentation and Care Planning 2 — Questions and Answers
Question 1: A restorative aide accidentally documents a session that was not performed. What is the correct action?
- Report the error to the supervising nurse and correct the documentation per facility policy (Correct answer)
- Leave the documentation as is to avoid questions
- Add a note saying the record was made in error without telling the supervisor
- Delete the entry without documenting a correction
Correct answer: Report the error to the supervising nurse and correct the documentation per facility policy
Documentation errors must be reported and corrected according to facility policy — typically by drawing a single line through the error, adding a note, dating, and signing — never erasing or deleting.
Question 2: What is the purpose of the interdisciplinary care plan in restorative services?
- To coordinate goals and interventions across all disciplines to provide consistent, resident-centered care (Correct answer)
- To list only nursing diagnoses and medical orders
- To replace the physician's plan of treatment
- To document billing codes for Medicare
Correct answer: To coordinate goals and interventions across all disciplines to provide consistent, resident-centered care
The interdisciplinary care plan integrates input from all team members — nursing, therapy, social work, dietary — to create cohesive, individualized goals and interventions.
Question 3: How often must care plans be reviewed and revised for long-term care residents under OBRA regulations?
- Quarterly and whenever there is a significant change in condition (Correct answer)
- Only annually at the resident's yearly review
- Whenever a family member requests a meeting
- Every 30 days regardless of resident status
Correct answer: Quarterly and whenever there is a significant change in condition
OBRA requires care plans to be reviewed and updated at least quarterly and whenever a significant change in the resident's condition occurs.
Question 4: What constitutes a 'significant change' that would trigger a new MDS assessment?
- A major decline or improvement in two or more areas of function that is not expected to resolve (Correct answer)
- Any single missed restorative session
- A temporary illness lasting less than 3 days
- A change in the resident's preferred meal time
Correct answer: A major decline or improvement in two or more areas of function that is not expected to resolve
A significant change is defined as a major decline or improvement in two or more areas of function that is not expected to resolve without intervention.
Question 5: Which abbreviation commonly used in restorative documentation means 'as needed'?
- PRN (Correct answer)
- QID
- BID
- NWB
Correct answer: PRN
PRN (from Latin 'pro re nata') means 'as needed' and is used in orders and documentation to indicate an intervention performed only when a specific condition arises.
Question 6: If a restorative aide disagrees with a goal on the care plan, what is the appropriate action?
- Discuss the concern with the supervising nurse or bring it up at the next care plan meeting (Correct answer)
- Change the intervention independently without informing the team
- Ignore the goal and implement their preferred approach
- Refuse to participate in the resident's care
Correct answer: Discuss the concern with the supervising nurse or bring it up at the next care plan meeting
Professional concerns about care plan goals should be communicated to the supervising nurse or raised at the care planning meeting — never acted on unilaterally.
Restorative Skills Documentation and Care Planning 2
A restorative aide accidentally documents a session that was not performed.
What is the correct action?