Here’s what you need to document

Document carefully for each episode of restraint or seclusion using the hospital’s restraint stamp or form, advises Kathleen Catalano, RN, JD, senior consultant to the Greeley Co., a health care professional consulting firm in Marblehead, MA, specializing in regulatory compliance.

"There should be space for why restraint was necessary, what alternatives were tried, clinical justification, type of restraint to be used, and the time," she says.

Include the following information, advises Catalano:

• the circumstances that led to the use of restraint;

• consideration or failure of nonphysical interventions;

• the rationale for the type of physical intervention selected;

• notification of the individual’s family, when appropriate;

• written orders for use;

• behavior criteria for discontinuation of restraint or seclusion;

• informing the individual of behavior criteria for discontinuation of restraint or seclusion;

• each verbal order received from a licensed independent practitioner;

• each in-person evaluation and re-evaluation of the individual;

• 15-minute assessments of the individual’s status;

• assistance provided to the individual to help him or her meet the behavior criteria for discontinuation of restraint or seclusion;

• continuous monitoring;

• debriefing of the individual with staff;

• any injuries that are sustained and treatment received for those injuries.