A nurse determines that a patient is behaving dangerously on the unit after he hit a staff member and swung at a patient. The nurse institutes 4-point restraints and then pages the physician for orders. Which of the following demonstrates appropriate documentation of the situation?

The patient's behavior was increasingly erratic during the shift. He was observed pacing, hitting the walls, and responding to internal stimuli. PRN medications were refused. Mental health workers KM and TD witnessed him threaten to "flatten" another patient in the day area and he hit mental health worker KM in the shoulder. He would not utilize seclusion and he kicked over a table when offered PRNs by this RN. 4-point restraints were initiated at 1330 hrs. The physician was called at 1355 and telephone orders for 4-points obtained.


•The documentation should be very specific, citing the behaviors observed, threats that might have been made, and any violent actions on behalf of the patient.

•You should always document less restrictive interventions attempted first, like PRN medications offered and the response, and if seclusion was attempted. 

•Always document the time that seclusion or restraints began and what time the order was obtained over the phone. The physician has 1 hour from the time restraints or seclusion were implemented to come to the unit for a face-to-face evaluation of the patient, and you need new order every 4 hours for seclusion or restraint to continue for psychiatric clients.

•Remember that your documentation is a legal document.

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