Violent (Behavioral) Restraint Documentation

Restraint or seclusion can be used when clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff, or others. A physician and/or APRN's order must be obtained for the use of restraint or seclusion. A face-to-face evaluation of the patient must be conducted and documented in the medical record within one hour after initiation of new orders and prior to writing a new order for restraint or seclusion, if the patient has been renewed orders for 24 consecutive hours. The face-to-face evaluation must include an evaluation of the patient's immediate situation, patient's reaction to intervention, patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion. 

To assist providers in documenting in Epic, a restraint and seclusion note type and a SmartText are available. 

Refer to the Tip Sheet: Provider Violent (Behavioral) Restraint Documentation