Range of motion (ROM) is the measurement of movement around a specific joint or body part, representing the full distance and direction a joint can move. Assessing ROM is a routine nursing practice that gauges musculoskeletal health, functional mobility, and overall safety. Accurate documentation is essential for communicating the patient’s status to the healthcare team, ensuring continuity of care and appropriate treatment planning. Precise charting also serves as a formal, legal record justifying interventions like physical therapy referrals.
Types of Range of Motion and Assessment Data
The nursing assessment of joint mobility is categorized into three distinct types of movement. Active Range of Motion (AROM) is assessed when the patient moves the joint independently, using their own muscles without assistance. AROM assessment reveals the patient’s muscle strength, motor control, and willingness to move the joint, providing a clear picture of functional capacity. Data collected includes the presence of pain, which may limit movement, or a full, smooth motion.
Passive Range of Motion (PROM) involves the nurse or a therapist moving the joint through the joint’s full arc while the patient remains relaxed. This assessment helps determine the joint’s anatomical limits and the integrity of surrounding ligaments and tendons. During PROM, the nurse notes joint stiffness, contractures, or crepitus (a grating sound or sensation suggesting friction). PROM often exceeds AROM because it bypasses the patient’s muscle strength or pain reluctance.
The third category is Active-Assistive Range of Motion (AAROM), where the patient initiates movement and the nurse provides gentle support to complete the arc. This movement is often used when a patient has muscle weakness or is recovering from injury or surgery. AAROM data helps determine if the patient is progressing toward independent movement and serves as the bridge between PROM and full AROM. The nurse documents the degree of assistance required (e.g., minimal or moderate support) and any pain reported during the assisted movement.
Standardized Terminology for Nursing Documentation
Accurate ROM documentation relies on standardized and precise professional language to ensure clear communication across disciplines. For joints with full, unhindered movement, nurses use the abbreviation FROM (Full Range of Motion) or WNL (Within Normal Limits). If movement is less than expected but sufficient for daily activities, the term WFL (Within Functional Limits) is used to reflect acceptable mobility despite minor restriction.
When a limitation is identified, the nurse must chart it using descriptive terms and anatomical abbreviations. For example, a restriction in the left elbow is documented using LUE (Left Upper Extremity), or RLE (Right Lower Extremity) for a hip limitation. Descriptive terms for the limitation include “slight limitation,” “guarded movement,” or “contracture noted,” which provides context to the reduced mobility.
For the most objective and precise data, especially when tracking progress, the nurse may use a goniometer to measure the joint angle in degrees. Charting a specific measurement, such as “LUE shoulder flexion limited to 90 degrees,” is more informative than a general description of limitation. Degree measurements should be used when a significant or quantifiable restriction is present, while descriptive terms suffice for subtle findings.
Procedural Steps for Clinical Charting
The final step is to formally enter the findings into the patient’s clinical record, typically within an Electronic Health Record (EHR) system. This information usually resides in specific flowsheets dedicated to physical assessment or within a narrative note section. Charting must be immediate and reflect the patient’s status at the time of assessment, requiring the nurse to date and time the entry precisely.
A concise, descriptive narrative entry is necessary to paint a complete picture, linking the type of ROM assessed with the specific findings and location. A comprehensive entry might be: “RUE AROM limited to 110 degrees shoulder abduction due to c/o 5/10 pain; PROM attempted with moderate resistance noted at 120 degrees; PT notified.” This entry incorporates the extremity, the type of ROM, the objective measurement, and the subjective complaint.
The nurse must also document any interventions performed or referrals made based on the ROM findings. Charting “Physical Therapy consulted for new onset RLE weakness” or “ROM exercises performed per protocol” ensures the care plan is updated and communicated. The entry must be authenticated with the nurse’s signature and professional credentials, making it a complete and legal record of the patient’s musculoskeletal status and resulting nursing action.