Restraint/Seclusion Initiation & Monitoring Note

Patient: [Patient name] | [MRN] | [DOB]

Location/Unit: [Location/Unit]

Service: [Service]

Author: [Author name] | [Role] | [Credentials]

Note Date/Time: [Clock time and date]

Episode Type: [mechanical/device restraint / physical hold/manual restraint / seclusion / combined restraint and seclusion]

Episode Start Time: [Clock time]

Episode Date: [Date]

Legal/Clinical Context: [Legal status and clinical context] (Include if applicable: involuntary hold, surrogate/guardian involvement, capacity concerns, or court orders.)

Initiation Summary

[Precipitating events and immediate safety risk] (Provide a concise behavioral narrative describing triggering events, specific observable actions, patient statements with direct quotes when available, and the immediate safety risk: [harm to self / harm to others / serious disruption creating imminent danger]. Use concrete behaviors rather than labels alone. Note any injuries present at initiation.)

Alternatives attempted prior to restraint/seclusion: [De-escalation approaches used and patient response] (Include verbal interventions, environmental changes, PRN medication offered/provided, engagement of support persons, sensory or comfort measures. Document patient response to each. If alternatives were not feasible due to urgency, state the reason.)

Order and Authorization

• Ordering Clinician: [Name, role]
• Order Time: [Clock time]
• Intervention Ordered: [Device type and configuration (e.g., 2-point/4-point) / seclusion room / physical hold category]
• Clinical Indication: [Behavioral and safety rationale tied to immediate risk]
• Order Duration: [Duration per policy]
• Discontinuation Criteria: [Specific behavioral or clinical criteria for release]
• Attending Notified: [Yes / No / N/A] (If yes: [Clock time] | [Notification method] | [Name notified])

Baseline Assessment

(Document findings at or immediately after initiation. If any element was not assessed, document "not assessed" with reason and plan for reassessment.)

• Respiratory status: [Work of breathing, breath sounds, airway patency]
• Circulation distal to restraint sites: [Pulses] | [Color] | [Warmth] | [Capillary refill]
• Vital signs: [BP] | [HR] | [RR] | [Temp] | [SpO2] | [Pain score if assessed]
• Mental status and agitation level: [Orientation, cognition, mood/affect, agitation severity with observable behaviors]
• Skin integrity: [Findings at contact points and any pre-existing injuries]
• Positioning and risk factors: [Position] | [Fall risk] | [Aspiration risk] | [Other relevant risks]
• Patient informed of: [Reason for restraint/seclusion] | [Criteria for release] | [Interpreter used: Yes/No; if yes, language and modality]

Face-to-Face Evaluation

(Include when required by policy for violent/self-destructive behavior or when performed.)

• Evaluator: [Name, role]
• Time Completed: [Clock time]
• Evaluation Summary: [Immediate situation] | [Reaction to intervention] | [Medical condition] | [Behavioral condition] | [Determination to continue/terminate with rationale]
• Orders modified: [Yes / No] (If yes, specify changes.)
• If evaluation outside required timeframe: [Reason] | [Mitigation actions taken]

Monitoring Log

(Repeat entry block at policy-defined intervals. Each entry must include clock time and observer identification. If any element is not assessed, document reason and plan to reassess.)

Monitoring Entry

• Observation Time: [Clock time]
• Observer: [Name, role]
• Patient status: [Observable behaviors and agitation level] | [Patient statements if relevant] | [Response to de-escalation] | [Ongoing justification for continued restraint/seclusion OR confirmation that release criteria are met]
• Physiologic and safety checks: [Respiratory status] | [Circulation distal to restraints: color, warmth, pulses, capillary refill] | [Mental status changes] | [Vital signs and SpO2 as indicated]
• Skin, ROM, and positioning: [Skin integrity at contact sites] | [Range of motion performed: limbs and time] | [Repositioning/pressure relief] | [Device fit and safety check]
• Basic care: [Toileting] | [Fluids/nutrition] | [Hygiene/comfort] | [Pain assessment/intervention]
• Observation modality: [direct line-of-sight / 1:1 observation / video/audio monitoring] (For seclusion: [Door status] | [Room safety confirmed])
• Interventions: [Medications given with time and response] | [Provider/charge notifications with reason] | [Patient education repeated]
• Escalation events: (Document if any occurred: respiratory compromise, cyanosis, mental status change, loss of consciousness, neurovascular compromise, skin injury, vomiting/aspiration risk, chest pain, seizure.) [Event] | [Actions taken] | [Outcome]
• Temporary supervised release: (Not discontinuation; for toileting, feeding, ROM, skin care under direct supervision.) [Start time] | [Stop time] | [Purpose] | [Supervising staff] | [Restraint reapplied: Yes / No]
• Order renewal: (If applicable.) [Renewal time] | [Authorizing clinician] | [Updated rationale] | [Updated release criteria] | [Monitoring plan confirmed]

Discontinuation

• Restraint Release Time: [Clock time / N/A]
• Seclusion Release Time: [Clock time / N/A]
• Reason for termination: [Release criteria met / Escalating medical risk / Other (specify)]
• Immediate post-release assessment: [Skin integrity] | [Circulation] | [Pain] | [Mental/behavioral status] | [Injuries identified and treatment provided]
• Notifications completed: [Parties notified with times]
• Plan to prevent recurrence: [Identified triggers] | [Preferred de-escalation strategies] | [Care plan modifications] | [Follow-up orders/referrals]

Debriefing

• Patient debriefing: (When clinically appropriate.) [Patient's perspective on events] | [What helped/worsened distress] | [Agreed prevention strategies] (If patient declined or unable to participate, note reason and plan to reattempt.)
• Team debriefing: [Precipitating factors] | [Alternatives that worked/did not work] | [Opportunities for earlier intervention] | [Environmental/system contributors identified]
• Trauma-informed and dignity protections: [Measures taken to minimize harm and preserve dignity]

Author Signature: [Name, credentials] | Date/Time: [Clock time and date]

Co-signature: (If required by policy.) [Name, credentials, role] | Date/Time: [Clock time and date]