Restraint/Seclusion Episode Note

Episode Header

(One note documents one continuous episode. If restraint/seclusion is discontinued and later re-initiated, create a new note.)

Episode Type: [Restraint / Seclusion / Simultaneous restraint and seclusion]

Category: [Behavioral (violent/self-destructive) / Non-violent (medical/safety)]

Location: [Unit and room/area]

Start Time: [Date and time intervention initiated] (If reconstructed from logs, state the source.)

End Time: [Date and time discontinued / Ongoing — last reassessment at date and time]

Author: [Name, role, credentials]

Precipitating Behavior and Safety Risk

[Narrative of precipitating behavior and immediate safety risk] (3–8 sentences. Begin with observable behaviors—what the patient did or said—before adding clinical interpretation. Label interpretations as such and tie to specific observations. Include direct patient quotes only if they directly drove safety decisions. For non-violent medical/safety restraint, focus on specific unsafe actions such as device removal attempts or climbing from bed.)

Primary behavior category: [Assaultive behavior / Self-harm / Property destruction with imminent risk / Severe agitation with imminent risk / Device removal attempt / Falls risk behavior / Other]

Less Restrictive Measures

(This section is mandatory. Never leave blank.)

[Alternatives attempted prior to restraint/seclusion and patient response] (Document specific measures such as verbal de-escalation, redirection, environmental modification, offering PRN medication, 1:1 observation, or involvement of support persons, and why each was ineffective.)

[If no alternatives were attempted, explicit justification] (E.g., active assault in progress; immediate serious danger precluded safe de-escalation attempts.)

Clinical Indication

Primary indication: [Statement that immediate physical safety of patient, staff, or others was at risk]

Least restrictive justification: [Why the selected intervention is the least restrictive option likely to be effective]

Relevant clinical factors: [Factors influencing risk or approach] (Only include factors explicitly known such as intoxication, delirium, medical instability, known trauma considerations, or positional risk factors. Do not speculate about unknown history. Omit if none applicable.)

[Attestation that the intervention is not for convenience, discipline, or retaliation]

Order and Notifications

Ordering Clinician: [Name and role]

Order Time: [Date and time] — [Obtained prior to initiation / Obtained during or immediately after emergency initiation]

Order Parameters: [Type of restraint/seclusion; maximum duration per policy; behavioral criteria for release]

Attending Notification: [Not applicable — attending placed order / Date, time, and method of notification]

Family/Guardian Notification: [Not indicated per policy / Date, time, method, and outcome]

Intervention Details

Restraint Type: [Manual hold / Mechanical — specify: wrist, ankle, vest, four-point, mitts, or other]

Seclusion Details: [Room/area, door status, environment safety check completed] (Include only if seclusion used.)

Patient Position: [Supine / Lateral / Sitting / Prone] (Document avoidance of positional compromise and airway protection. If prone positioning occurred, document risk mitigation.)

Medication: [Drug, dose, route, time] (Include only if administered as part of the event.)

Initial Safety Check: [Airway/breathing status; circulation; skin integrity; baseline distress/agitation level]

Patient Education: [Patient informed of reason for intervention, criteria for release, and how to request needs]

Monitoring Summary

Monitoring modality: [Continuous 1:1 / Intermittent checks every __ minutes / Video monitoring] (If detailed serial monitoring is recorded in a flowsheet, reference its location rather than duplicating values.)

• [Respiratory and cardiac status]
• [Circulation distal to restraints and skin integrity]
• [Range of motion and limb release per policy]
• [Vital signs]
• [Level of distress/agitation over time]
• [Hydration and nutrition offered; patient response]
• [Toileting offered; patient response]
• [Injuries to patient or staff] (Include evaluation and treatment if applicable.)
• [Ongoing de-escalation efforts and interventions to expedite release]

(For brief episodes, document at minimum initial and final assessment covering breathing, circulation, and injury status.)

1-Hour Face-to-Face Evaluation

(Required for behavioral [violent/self-destructive] restraint or seclusion. For non-violent medical/safety restraint, include only if required by local policy.)

Evaluator: [Name and role] (Must be in-person, not telemedicine.)

Time Completed: [Date and time]

Findings: [Patient's immediate situation; reaction to intervention; medical condition; behavioral condition; determination to continue or terminate] (If evaluation performed by RN or PA, document consultation with attending/LIP including time and resulting plan.)

Continuation or Discontinuation

If ongoing beyond initial stabilization:

[Unsafe behaviors persisting; why less restrictive options remain ineffective; specific criteria required for release; any step-down in restrictiveness] (Update as behaviors change.)

When episode ends:

Time Discontinued: [Date and time]

Condition at Release: [Observable status — calm, cooperative, oriented; injuries none or described; vitals stable or noted]

What Allowed Release: [Specific observable change that justified discontinuation] (Do not state "resolved" without describing what changed.)

Post-Release Plan: [Observation level; medication plan; milieu plan; safety plan updates]

Debriefing

(Include if completed or required by policy. If deferred, document reason and planned timing.)

Patient Debriefing: [Date and time] — [Patient perspective in their own words; coping strategies identified; supports offered for distress; grievance information provided if applicable]

Team Debriefing: [Date and time] — [What worked; what did not; proposed prevention strategies]

Plan-of-Care Update: [Summary of treatment plan modifications prompted by episode — triggers, preferred interventions, observation level, safety planning]

Adverse Events

(Include only if applicable; otherwise omit entire section.)

• [Injuries sustained (patient or staff) with evaluation and treatment performed]
• [EMS activation, transfer, code, or rapid response]
• [Equipment failure or malfunction]
• [Sentinel event reporting completed]