EMS Behavioral Health Crisis/Restraints & Sedation Note

Date/Time: [Date and times for dispatch, arrival, patient contact, interventions, and transport milestones] (Use 24-hour format.)

Unit/Agency: [Unit identifier and EMS agency name]

Crew: [Crew names, roles, and certifications]

Incident #: [Incident or call number]

Patient: [Full name, DOB, age, sex] (If identity unknown, use "Unknown adult [male/female], approx age __" and state what identifiers were used.)

Scene: [Location type and environmental factors/risks] (Include hazards, crowd/bystanders, confined spaces, heat/cold exposure.)

Legal Status at Contact: [Voluntary EMS contact / Involuntary hold initiated / Law enforcement custody] (Document existing paperwork/orders, who initiated them, and times.)

Chief Concern & Initial Presentation

[Reason for EMS activation and arrival snapshot] (1–3 sentences describing observed behavior, level of distress, psychomotor activity, coherence, cooperation, and immediate safety threat. Use objective, behavior-based language. Include verbatim patient statements in quotes when relevant.)

Threat Assessment & Scene Safety

• Threats to self: [Suicidal statements/behaviors, attempts, access to means] (Include what was seen/heard and by whom.)
• Threats to others: [Explicit threats, assaultive actions, weapon access/possession] (State who secured weapons and when, if applicable.)
• Engagement level: [Cooperative / Minimally cooperative / Unengageable] (Describe attempts to engage and patient response.)
• Safety actions taken: [Staging, LE backup, PPE, bystander management, scene control measures]
• Baseline agitation severity score: [Time – Scale (e.g., RASS): Score]

Capacity & Consent Basis

[Capacity assessment and consent basis used] (Document patient's capacity to accept/refuse evaluation, transport, and medication. Specify consent basis: [informed consent / implied consent due to incapacity with emergent need / guardian or surrogate consent]. Include one sentence explaining why the chosen basis applies.)

Primary Assessment

• Initial vitals: [Time – HR, BP, RR, SpO₂, Temp, Glucose, Pain if obtainable] (Temperature and glucose strongly recommended in severe agitation.)
• Focused exam: [Mental status, pupils, skin signs, respiratory effort, signs of head injury, stimulant toxidrome features, injury check] (If exam limited by safety, state: "Exam limited by agitation; performed visually at distance until scene secured.")

History & Collateral

[HPI paragraph: onset, precipitating events, escalation pattern, prior similar episodes, substance use/ingestion, patient statements in quotes, observed behaviors] (If unobtainable, state: "Unable to obtain due to agitation/no historian available.")

• Relevant past history: [Psychiatric diagnoses, seizures, diabetes, other pertinent PMH]
• Medications: [Current medications, adherence if known]
• Allergies: [Drug/food allergies and reactions]
• Prior adverse reactions to sedatives: [Agent and reaction if known, or unknown]
• Collateral sources: [Source roles and key information obtained] (Family, bystander, LE, facility staff.)

De-escalation Attempts

(Required if any restraint or sedation occurred.)

[De-escalation strategies attempted and patient response to each] (Document which of the following were attempted: calm approach with single speaker, validation/empathy, offering choices and clear limits, reducing stimuli or relocating, offering oral/voluntary medication, engaging trusted person. If de-escalation was not feasible, explain why—immediate violence, weapon, active self-harm, inability to safely approach.)

Indication for Restraint/Sedation

(Required if any restraint or sedation occurred.)

[Clinical reasoning for intervention] (Describe immediate safety risk to patient/crew/others and/or interference with evaluation of potentially life-threatening medical causes. Reference de-escalation attempts or explain why they were unsafe. State why chosen modality was the least restrictive safe option. Include ordering authority: standing protocol name or medical control contact with name/ID, time, and orders given.)

Physical Restraint Details

(Include only if physical restraints were applied by EMS or present on arrival.)

• Restraints present on arrival: [Type, who applied (LE/facility), patient position, airway/chest assessment, any EMS-requested modifications]
• EMS-applied restraints: [Time applied, personnel assisting, device/method, limbs restrained, patient position, positions explicitly avoided with safety rationale] (Document that restraints were applied to permit medical care and safe transport.)
• Criteria for loosening/removal: [Behavioral/clinical criteria for adjustment]

Pharmacologic Sedation

(Include only if sedating medication was administered for agitation.)

Pre-sedation assessment: [Time – Baseline vitals, agitation score, airway risk factors (vomiting, obesity, intoxication, facial trauma), monitoring setup initiated]

Time	Medication	Dose	Route	Indication	Ordering Authority	Response	Adverse Effects/Interventions
[HH:MM]	[Agent]	[Dose/units]	[IM/IV/IN/PO]	[Indication]	[Protocol or MD name/ID]	[Time to effect, agitation score change, clinical description]	[Effects and interventions if any]
[HH:MM]	[Agent]	[Dose/units]	[Route]	[Indication]	[Authority]	[Response]	[Effects/interventions]

• Post-sedation monitoring plan: [Continuous observation, vitals and scoring intervals, respiratory monitoring, position and airway precautions]
• Complications: [Hypoxia, apnea, aspiration, hypotension, dystonia, emergence reaction, airway intervention—times, treatments, responses] (Omit if none.)

Reassessment & Monitoring Log

(Mandatory if restraint or sedation occurred. Each entry must reflect current assessment; do not copy forward.)

• [HH:MM – Agitation/Sedation score; Mental status; RR, SpO₂, EtCO₂ if used; HR, BP; Temp if relevant; Restraint checks (distal circulation, skin)]
• [HH:MM – Agitation/Sedation score; Mental status; Airway/Breathing; Circulation; Restraint checks]
• (Add entries at protocol-defined intervals and with any change in status or intervention.)

Law Enforcement Interface

(Include when LE was involved.)

• Custody status: [Who had custody, whether patient was free to leave, relevant legal authority/paperwork]
• LE restraints used: [Type, who applied, position, EMS requests for repositioning/removal/adjustment for medical safety]
• Use-of-force events with medical relevance: [Neutral description of reported/observed events with medical consequences: struggle duration, prone positioning time, TASER/OC exposure, head trauma; associated assessments and treatments] (Omit if none.)

Transport & Handoff

Destination: [ED / Specialty center] (Document rationale: medical causes not excluded, sedation given, injuries, hyperthermia concern.)

Transport conditions: [Patient position, restraint status, monitoring modalities, escort personnel]

SBAR Handoff:

• Situation: [Reason for call, current threat level]
• Background: [Key history/collateral, pertinent PMH/meds/allergies]
• Assessment: [Vitals trend, agitation score trend, injuries, suspected contributors]
• Recommendation: [Ongoing monitoring needs, pending complications, timing and total doses of medications, restraint times]

Disposition

• Status at transfer of care: [Calm/cooperative / Sedated; airway status; vital stability; restraints on/off]
• Injuries: [Patient or provider injuries, care provided, reporting per policy] (Omit if none.)
• If refusal of care/transport: [Capacity determination, risks explained, safety plan or LE disposition] (Omit if transported.)

(Documentation standards: Use objective, behavior-based descriptions of what was seen, heard, measured, and done. Avoid pejorative language and contested labels; prefer "severe agitation with altered mental status" with specific observable findings. For critical elements—identity, capacity/consent, de-escalation attempts, restraint justification, medication times/doses, monitoring/vitals—use "Unknown," "Unable to obtain," or "Not applicable" rather than leaving blanks. Time-stamp all key events and reassessments.)