Related Experiment Video
Updated: Aug 15, 2026
Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit
Published on: September 30, 2020
Reduced Joint Range of Motion in Nursing Home Residents: A Documentation Gap With Functional Implications
Shennah Austen1, Annelies Boonen2, Jos Schols3
1Cicero Zorggroep, Zuid-Limburg, The Netherlands; Department of Health Services Research, Maastricht University, Maastricht, The Netherlands; School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands.
Objectives:
To ascertain to what extent reduced range of motion (ROM) and tender joints identified through a standardized physical examination were documented in the medical records of nursing home residents and to describe functional dependence and pain scores in relation to documentation status.
Design:
Cross-sectional study.
Setting And Participants:
One hundred nursing home residents of Cicero Zorggroep, the Netherlands.
Methods:
Joint findings were assessed by standardized physical examination, including ROM across 15 joint groups by passive movement and the 68 tender joint counts. Medical records were reviewed for documentation of findings for the same joint, the presence of a rheumatic and musculoskeletal disease diagnosis, and pharmacologic and nonpharmacologic treatment. Functional dependence was assessed using the Katz Index and pain using a visual analog scale or the Pain Assessment Checklist for Seniors with Limited Ability to Communicate.
Results:
Among residents (mean age, 83.3 years; 66% female), reduced ROM was identified in 69%, yet documented in the medical record in only 4%. Tender joints were identified in 48% of residents, with a documentation rate of 46%. Hip ROM limitation was the most prevalent finding (51%), yet was not documented in a single case. Residents with undocumented ROM limitations showed significantly higher functional dependence than residents without ROM limitations, particularly in transferring (P < .001), whereas pain scores did not differ significantly between these groups (visual analog scale, P = .426). Most residents received analgesics; rheumatic and musculoskeletal disease-specific medication was used by fewer than 15% across all groups.
Conclusions And Implications:
A documentation gap exists for mobility-relevant joint findings in nursing home residents. The differential documentation rates may reflect the absence of pain as a clinical trigger for ROM documentation. Systematic physical examination with explicit documentation of ROM limitations could support more targeted care planning and treatment decisions.
Related Concept Videos
01:29Documentation in Long-Term and Home Healthcare Setting
Long-Term Care Facilities
01:30Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
01:26Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
01:06Legal Guidelines for Documentation
01:15Methods of Documentation VI: Case Management Model
For example, a patient with a chronic illness...
01:28Formats for Nursing Documentation
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...