Procedure Note - Restraint Note(s)

Initial Restraint Note:

Patient felt to meet indications for [chemical/physical/chemical and physical restraint] due to concern that the patient presents an imminent threat to themselves and staff.  Attempts at de-escalation [were unsuccessful/could not be attempted due to agitation and violent behavior].  We considered risks of the use of [chemical/physical] restraints, and felt that the benefits of harm reduction outweighed these risks at this time.

Chemical restraint was initiated with [antipsychotic-Haloperidol (Haldol) ## mg IM/IV/Olanzapine (Zyprexa) ## mg PO/IM/IV/Ziprasidone (Geodon) ## mg IM and benzodiazepine-Lorazepam (Ativan) ## mg IM/IV/Midazolam (Versed) ## mg IM/IV].

Physical restraints were felt to be necessary due to [continued agitation despite use of chemical restraints for rapid tranquilization/due to continued agitation while awaiting maximal effects of chemical restraint/inability to safely administer chemical restraints due to agitation and aggressive behavior].

I personally evaluated the patient before and after restraint placement [along with my attending/resident Dr. NAME] as documented in the history and physical exam section.  We discussed plan for nursing to reassess the patient every [10-15] minutes, and will plan to repeat our exam within 1 hour with the goal of potentially discontinuing some or all of the applied physical restraints.

Continued Restraint Note

Patient felt to still meet indications for physical restraint at this time due to concern that the patient still presents an imminent threat to themselves and staff.  We again made unsuccessful attempts at de-escalation which [were unsuccessful/still could not be attempted due to agitation and violent behavior].  We considered risks of the continued use of physical restraints, and felt that the benefits of harm reduction outweighed these risks at this time.

I personally evaluated the patient before and after restraint placement [along with my attending/resident Dr. NAME] as documented in the history and physical exam section.  We discussed plan for nursing to reassess the patient every [10-15] minutes, and will plan to repeat our exam within 1 hour with the goal of potentially discontinuing some or all of the applied physical restraints.

Discontinuing Restraint Note

Patient felt to no longer meet indications for physical restraint at this time with plan [to discontinue all restraints at this time/to transition from 4-point to 2-point and ultimately discontinue all restraints if patient remains calm and cooperative].  Patient noted to have no evidence of complications from restraint use, such as significant soft tissue injuries or rhabdomyolysis among others.

I personally evaluated the patient before and after restraint placement [along with my attending/resident Dr. NAME] as documented in the history and physical exam section.

Note: Laws regarding the use of restraints vary by state and hospital, so you should be aware of the specific requirements at your institution.  These should all be time-stamped and signed for legal purposes.  It is absolutely essential that you re-evaluate any patient you place into physical restraints frequently with the goal of always using the least restrictive method to control the agitated patient.

https://ercast.libsyn.com/art-of-the-chemical-takedown
http://www.emdocs.net/agitation/