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 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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