How to Document a Restraint Application
Restraint use is among the most closely reviewed things a nurse can document. The record has to show that restraint was a last resort, why it was needed, how it was applied and monitored, and when it ended.
The short answer
Chart the behaviour or risk that led to restraint, the alternatives tried and their results, the type used, the authority (consent, order or emergency basis under your policy and law), the time applied, monitoring, effects on the patient, and the time it was removed. Rules differ by province and setting; for example, the Canadian Nurses Protective Society (CNPS) notes that Ontario has the Patient Restraints Minimization Act, and some other provinces have their own legislation or policy.
What counts as a restraint
CNPS describes restraints as environmental (for example, seclusion), mechanical or physical (devices or techniques that limit movement), or chemical (psychoactive medication used to inhibit behaviour rather than treat a medical symptom). Your employer's policy defines what must be documented as a restraint in your setting.
What to document
- Why: the specific behaviour or risk (for example, pulling at an IV line, attempting to climb out of bed), described objectively.
- Alternatives tried: verbal approaches, redirection, monitoring, environmental changes, with the result of each.
- Authority: consent from the patient or substitute decision-maker, an order if your policy requires one, or the emergency basis. CNPS notes that emergency use without consent is for situations of serious threat after alternatives have failed, with consent sought afterward.
- Method: what device or measure, where applied, and by whom.
- Times: applied and removed.
- Monitoring: observation frequency per your policy, with each check and finding recorded.
- Effects: patient response, skin and circulation checks, comfort, and care needs such as hydration, toileting and repositioning as your policy requires.
- Chemical restraint: drug, dose, route and administration details.
- Communication: who was told, including family or the substitute decision-maker, and when.
Example (fictional patient)
Note
1400: Patient Q, 82, post-operative delirium, repeatedly pulling out IV line and trying to climb over bed rails, states, "I have to go home." Redirection attempted at 1330 and 1345 without lasting effect; sitter requested; bed lowered and room made quieter. 1410: Dr. assessed, order obtained per policy for soft wrist restraint, right wrist, to protect IV line. Daughter (substitute decision-maker) informed by phone at 1415 and agreed. Restraint applied at 1420 by two nurses; two finger widths clearance, skin intact, hand warm, capillary refill 2 seconds. Checks at 1435 and 1450: skin intact, circulation unchanged, patient calmer, offered fluids. 1530: Dr. reassessed; restraint removed at 1535; no skin changes. Alternatives continue, sitter at bedside.
The intervals and finger-width check above are fictional. Follow your employer's policy.
Common mistakes
- Writing "agitated" without describing the behaviour.
- No record of alternatives tried.
- Missing application or removal times.
- Monitoring checks that are not individually recorded.
- No reassessment of whether the restraint is still needed.
- No record of consent, order or emergency basis.
Template
Behaviour or risk (objective): ___ Alternatives tried and results: ___ Authority (consent, order, emergency): ___ Type, site, applied by: ___ Time applied: ___ Monitoring times and findings: ___ Reassessment of need: ___ Time removed: ___ Notified (who, when): ___
Where Fiabita fits
Fiabita's "Clean up my note" tool can help you reword rough notes into clearer, more objective language, and its SBAR handoff and incident-report tools ask guided questions so fewer details get lost under pressure. The output is a draft: you remain responsible for what goes into the record, and it does not check compliance with your regulator or employer. Do not enter information that could identify a real patient, and follow your workplace policy on which tools may be used.
FAQ
Q: Do I always need an order?
Requirements differ by province, setting and type of restraint. Check your employer's policy and the applicable legislation.
Q: What if the patient refuses?
Competent patients can refuse; CNPS notes patients retain the right to refuse restraints. Escalate and document, and follow your policy.
Q: How often should I check?
Your employer's policy sets monitoring intervals. Record each check as it happens.
Sources and further reading
- CNPS InfoLAW: Patient Restraints
- College of Nurses of Ontario: Documentation practice standard
- CNPS: Documentation for Nurses (guidelines)
Always check the current version of each source and your own regulator's standards; links and wording can change.