Restraints & Documentation
High-Alert ProceduresThe steps
- Exhaust alternatives FIRST and document them (sitter, redirection, family, environment changes)
- Provider order required — never PRN; face-to-face evaluation within the required window
- Least restrictive device that works; correct application with two-finger slack, quick-release ties to the bed FRAME (never rails)
- Monitoring per policy (often q15min): circulation, skin, position, needs
- Release and range-of-motion at required intervals; offer toileting, fluids, food
- Renewal per policy — orders expire; track the clock
🛡 Never skip
Restraint documentation is a legal document of a liberty restriction — treat every checkbox as testimony Document behavior requiring restraint, alternatives tried, patient/family education, and every monitoring cycle
Common mistakes
- "People are fired over restraint documentation" — missed q15 checks are the most common audit failure
- Tying to side rails (injury on rail movement)
- Letting the order lapse while restraints stay on — that's an unauthorized restraint
Source: Lippincott Nursing Procedures, 9th ed.; CMS Conditions of ParticipationReference only — verify against your facility's policy.
