Form 3643 PDF Details

Understanding the complexities of patient care within the Texas Department of Aging and Disability Services requires familiarity with various forms, among which the 3643 form is pivotal. Instituted in November 1996, this form bridges crucial aspects of discipline-specific care, including physical therapy (PT), occupational therapy (OT), and speech therapy (ST), under the umbrella of the Nursing Restorative Care Program. It meticulously records the goals set for an individual's care, the frequency and types of approaches pursued, and the corresponding outcomes, ensuring a structured plan of care is both established and adherently monitored. Detailed sections capture the initiation of restorative care, document patient responses over weekly intervals, and assess the appropriateness and effectiveness of the care plan, urging regular updates and adjustments as necessary. Additionally, this form places significant emphasis on accountability and follow-through by requiring signatures from both the responsible nurse and the therapists involved, underlining its role in maintaining a high standard of patient care. Through sections dedicated to evaluating the ongoing suitability of the care plan and outlining any recommended changes to the program or goals, the form functions as a dynamic document that evolves in response to the resident's progression or changing needs, thereby encapsulating a holistic approach to restorative care within the state’s healthcare system.

QuestionAnswer
Form NameForm 3643
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform nursing restorative care, form restorative care program printable, form nursing restorative, 3643 restorative nursing program forms

Form Preview Example

Texas Department of Aging

and Disability Services

Discipline

 

 

Month and Year of Service

PT

OT

ST

 

 

 

 

 

SECTION I – PLAN OF CARE

Form 3643

November 1996

NURSING RESTORATIVE CARE PROGRAM

Goals

1.

2.

3.

4.

Approaches (with frequency)

Date Restorative Initiated

1.

2.

3.

4.

5.

Signature–RN

 

Signature–Therapist

Signature–Therapist

 

 

 

 

SECTION II – APPROACHES:

W=Withheld

R=Refused D=Discharged

Document in Weekly Notes the reason if “Withheld” or “Refused.”

APPROACHES

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26 27 28 29 30 31

Approach #1

Approach #2

Approach #3

Approach #4

Approach #5

NOTE: Each person who initials the approaches (above) must initial and sign below.

Initials

 

Signature

 

Initials

 

Signature

 

Initials

 

Signature

 

 

 

 

 

 

 

 

 

 

 

Initials

 

Signature

 

Initials

 

Signature

 

Initials

 

Signature

Resident Name:

 

Room No.:

Form 3643

Page 2

SECTION III – DOCUMENT RESIDENT’S RESPONSE AND PROGRESS TOWARD GOALS(S):

Week 1 – Response

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

Date

Week 2 – Response

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

Date

Week 3 – Response

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

Date

Week 4 – Response

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

Date

Week 5 – Response

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

Date

SECTION IV – MONTHLY REVIEW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. Is the Plan of Care appropriate?

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

B. Are changes to the Restorative Program recommended?

 

 

 

 

 

 

 

Yes

No

 

Are changes recommended to the Goals?

 

 

 

 

 

 

 

 

 

 

Yes

No

 

Are changes recommended to the Approaches?

 

 

 

 

 

 

 

 

 

Yes

No

 

If YES to any items in B, update next month’s SECTION I–PLAN OF CARE with the changes.

 

 

 

 

 

 

 

Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Continue Program?

 

 

Yes

No

D. Discharge to basic nursing?

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature–Licensed Staff

 

 

 

Date

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step 1 to writing form nursing restorative care

In the APPROACHES, Approach, Approach, Approach, Approach, Approach, NOTE Each person who initials the, Initials, Signature, Initials, Signature, Initials, Signature, Initials, and Signature box, put down your data.

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The application will ask for additional information as a way to instantly prepare the field Week Response, Week Response, Week Response, Week Response, Signature, Date, Signature, Date, Signature, Date, Signature, and Date.

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Please make sure to include the rights and responsibilities of the sides inside the Week Response, Signature, Date, SECTION IV MONTHLY REVIEW, Is the Plan of Care appropriate, B Are changes to the Restorative, Are changes recommended to the, Are changes recommended to the, If YES to any items in B update, Comments, Yes Yes Yes Yes, and No No No No section.

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