Md. Code Regs. 10.21.12.10

Current through Register Vol. 51, No. 12, June 14, 2024

Section 10.21.12.10 - Documentation

A. Restraint Orders. A physician shall:

(1) To initiate the use of restraint:

(a) Enter an order in the patient's medical record; or

(b) Authorize an order to be written by a registered nurse on the physician's order sheet in the patient's medical record:

(i) Indicating that physician's verbal order for restraint; or

(ii) Directing the release of the patient and the rationale for that release;

(2) Countersign all verbal orders within 24 hours of the order's being written; and

(3) Include in the order for restraint:

(a) The date and time that the order was written;

(b) The specific type of restraint to be used;

(c) The maximum duration of restraint from the time that the restraint was initiated;

(d) The specific rationale for restraint;

(e) Special precautions, if any, to safeguard the patient;

(f) The physician's signature; and

(g) In the case of a verbal order, the names of both the ordering physician and the registered nurse who received the verbal order.

B. As soon as possible after implementation, but not later than the close of the shift, staff shall:

(1) Document the implementation of restraint in the patient's medical record; and

(2) Include in the documentation the following information:

(a) A description of the specific behavior leading to restraint;

(b) Whether and which less restrictive techniques were used, and, if not, why not;

(c) Whether a formal call for facility staff response was required, the names of staff assisting in the restraint, and the circumstances while restraining the patient;

(d) The readily observable physical condition of the patient;

(e) The date and time of the restraint and signature of the recorder;

(f) Whether the patient was permitted to wear the patient's own clothes or other attire and, if not, the reason or reasons for this; and

(g) A description of any physical injury to either the patient or others resulting from placement of the patient in restraint.

C. While a patient is restrained, staff shall document the clinical interventions employed, including those listed in Regulation .08 of this chapter.

D. Release from Restraint.

(1) When a physician clinically determines that a patient is to be released from restraint, the physician shall:

(a) Order the release and write, sign, and date a note indicating the rationale for the release; and

(b) If verbally ordering the release, write, sign, and date the note not later than 24 hours after a verbal order to release.

(2) When a registered nurse clinically determines that the release of the patient before the maximum period specified on a physician's order is appropriate, the registered nurse shall:

(a) Order termination of the restraint with or without a physician's order, unless the physician's order specifically requires physician concurrence with the termination; and

(b) Document, sign, and date the rationale for the termination of restraint in the patient's medical record.

Md. Code Regs. 10.21.12.10