By Amy Niemas, RN-BC, BSN, MSW, Clinical Content Director · Psychiatric Registered Nurse

Last updated: August 28, 2026

How to Chart Patient Restraints and the Post-Restraint Evaluation

The federal requirements described here come from 42 CFR 482.13, which applies to hospitals, so if you work in long-term care or home health your setting is governed by different regulations and your facility policy is the standard to follow.

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Why This Matters

Regulatory bodies: CMS Conditions of Participation, Joint Commission Hospital Standards, State Boards of Nursing

Restraint documentation falls under 42 CFR 482.13, which outlines the Centers for Medicare & Medicaid Services (CMS) hospital Conditions of Participation regarding patient rights. The regulation specifies what your chart must include: the behavior that warranted the restraint, the less-restrictive alternatives attempted, the time-limited order, the monitoring performed, and the patient's response, along with the rationale for continuing. Joint Commission hospital standards align with CMS rules, and state boards of nursing expect your documentation to reflect nursing assessments conducted as indicated in the chart. A restraint chart is the record most likely to be reviewed by someone other than the next nurse. Specifically, surveyors examine restraint episodes, as do attorneys. As such, correct documentation is essential. In one case study, a nurse's restraint flowsheet, which included her honest note about the single 15-minute check she missed and the reason for it, supported her defense through two trials over 12 years. The chart is not merely paperwork after the crisis; it serves as proof that the crisis was managed correctly.
  1. 42 CFR 482.13, Condition of Participation: Patient's Rights — Cornell Law School, Legal Information Institute
  2. Understanding the new standards for patient restraint and seclusion — American Nurse Journal
  3. Assessing and documenting patient restraint incidents (Woodard J.) — American Nurse Journal (2015)
  4. State Operations Manual, Appendix A: hospital interpretive guidelines for 42 CFR 482.13 — Centers for Medicare & Medicaid Services (CMS)
  5. Nurse case study: alleged failure to properly assess and monitor the impaired, restrained patient — Nurses Service Organization (NSO)

Categories and Types of Restraints

There is a lack of uniformity and clarity in describing different kinds of restraints, such as physical/mechanical, manual, chemical, environmental/seclusion, and violent/psychiatric/behavioral versus non-violent/med-surg restraints. All are terms used in different settings. Federal regulations categorize restraints into two types, each with specific documentation requirements. Violent restraint, which 42 CFR 482.13 calls "violent or self-destructive" restraint and which is often called psychiatric or behavioral restraint, manages a patient who poses an immediate physical danger to themselves or others. Non-violent restraint, sometimes called med-surg restraint, protects medical care, such as using soft wrist restraints or mittens on a confused patient who is pulling out an IV line. The behavioral category requires new orders frequently (usually every 4 hours), a 1-hour face-to-face evaluation, and intensive 1:1 monitoring. In contrast, the medical category does not have these clocks; its specifics follow your facility's policy. Within psychiatric restraints there are specific types of physical/mechanical restraints used, such as wrist and ankle straps, restraint chairs, or restraint beds. Manual restraints, such as hands-on control, also fall in this domain. Chemical restraint refers to the use of medication, such as an antipsychotic or a benzodiazepine, to control highly aggressive or dangerous behavior. Note that a medication only counts as a restraint when it is used to manage behavior, and is not a standard treatment or dose for the patient's condition. A routine PRN given as part of the treatment plan is not automatically a chemical restraint. Seclusion is isolating the patient by restricting their ability to leave a certain area. Follow your facility's procedures for category names. Always remember to chart the behavior that led to the restraint. If the behavior that triggered restraint included suicidal or homicidal statements, it requires its own documentation trail. This safety assessment guide explains how to chart suicidal ideation, 1:1 observation, and safety contracts alongside the restraint record.

The Restraint Order: Time Limits, Renewals, and the Absence of PRN Restraint

Restraint orders are never standing orders and never PRN (as needed). 42 CFR 482.13 states this directly. An order like "restraints PRN for agitation" is not a valid restraint order. Every episode needs its own current, time-limited order. A restrained patient requires continuous observation, and in psychiatric settings that means a 1:1 sitter or safety assistant at the bedside at all times, with the patient never left alone. Federal rules also require continuous face-to-face monitoring whenever restraint and seclusion are used together. Outside of that, the observation level is set by your facility's policy, so check what yours requires before assuming an interval check is enough. For violent/psychiatric restraint, the order expiration is age-tiered by federal rule: - 4 hours for adults 18 and older - 2 hours for children and adolescents ages 9 to 17 - 1 hour for children under 9 Orders may be renewed within those limits for up to 24 hours. CMS interpretive guidance allows the order renewal to happen on the nurse's reassessment: you reassess the patient, call the provider before the order expires, and report your findings. The 1-hour face-to-face evaluation is tied to the start of the restraint, not to renewals; the federal rule does not require a new face-to-face with each renewal inside the 24-hour window, though your facility or state may set a stricter standard. After 24 hours, a physician or other licensed practitioner must personally see and assess the patient before writing a new order. Follow your facility's guidelines for reassessment. Just because an order does not expire for several hours does not mean that you are not assessing and reassessing your patient during that time. The patient remains under continuous observation for as long as the restraint is in place. In an emergency, applying the restraint before the order exists is expected. For example, if a patient who is actively striking staff is restrained, then the order is obtained as soon as possible. Chart the real sequence with real times. A note showing restraints at 1415 and the verbal order at 1422 is honest and compliant. For non-violent/med-surg restraint, order renewal follows hospital policy. That makes your facility's policy the document to know, because it is the standard your chart is audited against.

The 1-Hour Face-to-Face Evaluation

When restraint or seclusion is used for violent or self-destructive behavior, the patient must be seen face-to-face by a qualified evaluator within 1 hour after the intervention starts. The evaluation covers the patient's immediate situation, their reaction to the intervention, their medical and behavioral condition, and whether the restraint needs to continue. This only applies to violent/behavioral restraint, and not to non-violent/med-surg restraint, which is the most common point of confusion on med-surg floors. It is often assumed that only a physician or provider can perform the 1-hour face-to-face evaluation; however, so can a registered nurse who has been trained under the hospital's program. The old belief that "the doctor has to come do the face-to-face" is outdated, and waiting for a physician while the 1-hour window closes creates exactly the gap a survey catches. Follow your facility's guidelines for who qualifies to do the 1-hour evaluation. When a trained RN performs the evaluation, they must consult the attending physician or other licensed practitioner as soon as possible afterward, and that consult must appear in the chart. The evaluation without the consult note is a documentation gap. Chart who you consulted, when, and what was decided. Charting example: "1500: 1-hour face-to-face evaluation completed by this RN (restraint initiated 1415). Patient remains agitated, pulling against restraints. Denies pain. Skin intact, circulation to extremities intact. Continued restraint warranted due to ongoing attempts to strike staff. Dr. Smith consulted by phone at 1510, agrees with continued restraint."

What to Chart at Initiation of Restraints

The initiation note answers three questions a reviewer will ask in order: what was the patient doing, what other interventions did you try, and what did you do in response. The regulation requires all three, plus the patient's response to the interventions. The behavior comes first, in observable terms, such as "patient suddenly agitated; threw items in room, slammed door, overturned bedside table, and continued advancing toward staff despite verbal redirection." Interpretations like "patient was aggressive" do not hold up; direct and clear observations do. (The objective versus subjective charting guide walks this distinction in depth.) The alternatives come second. Verbal de-escalation, reduced stimulation, offering a PRN medication the patient accepted or refused, and moving the patient to a quieter room are all examples of possible interventions. Name what was tried and how the patient responded. "Less restrictive interventions attempted" is the exact element the regulation lists, and evidence must be provided to support this rule. Charting example: "1410: Patient agitated after phone call, began pacing and yelling. Threw items in room, slammed door, and overturned bedside table. Verbal de-escalation and redirection attempted x2 by this RN, charge RN, and floor staff. Patient continued to escalate. Postured at staff. Struck CNA in the face with closed fist. Offered PO Haldol per existing order, patient refused. 1415: Patient escorted to bed by staff, and bilateral four-point restraints applied. Per Dr. Smith telephone order received 1422 for violent behavior endangering staff. Patient continues to pull against restraints and scream at staff. No injury observed. Remains with 1:1 safety assistant. Will review plan for release with patient when agitation decreases."

The Monitoring Flowsheet: What to Include in Every Entry

The monitoring entry set remains generally consistent across facilities. Each reassessment entry includes the behavior justifying continued restraint, or a reevaluation of whether the patient still needs the restraint; mental status, including orientation; the number and type of restraints and their placement; circulation and sensation of the restrained extremities; range of motion (ROM), vital signs, skin condition, care provided, and food, fluid, and toileting offered. This full reassessment typically occurs every 2 hours. Charting frequency often confuses nurses. Federal regulation states the interval is "determined by hospital policy." The common practice is to document every 15 minutes for violent restraint and every 2 hours for medical restraint. These intervals reflect facility policy, not federal law. Review your facility's restraint policy, as its intervals set the standard against which your flowsheet will be audited. Also remember that the 1:1 sitter for psych/violent restraints remains with the patient for the duration of the restraint time but might only document in the chart every 15 minutes, per facility guidelines. The sitter is present for safety and can do the 15-minute checks, but the nurse must do the reassessments, and should of course be alerted if there is any change in patient status in the interim period. A blank cell in the chart indicates that monitoring was not done. There is no way to fix charting for observation that did not occur, but you can document a missed check by including the time and the reason. In the case study mentioned in the introduction, the nurse's note explaining the one check she missed (due to caring for a critically ill patient) provided credibility to her record through two trials. An honest late entry stating "late entry" is always better than omitting or not explaining it. This principle also applies to routine safety check documentation, but a restraint flowsheet raises the stakes.

Discontinuation and Post-Restraint Evaluation

Restraint ends at the earliest safe moment, and charting needs to reflect that. By the time restraints come off, the crisis is over, the adrenaline is gone, and the discontinuation note is the entry most likely to be forgotten entirely. However, it is still an essential piece of the puzzle: treat it as part of the episode, not as an afterthought. The discontinuation and post-restraint documentation includes: the time of release, the behavior that justified release, the patient's behavior and condition at release with a skin and circulation check of the restrained extremities, any injuries found and what was done about them, vital signs, and any other categories per your facility's policy. The last stage of the restraint process is the debrief. Most facility policies, following Joint Commission-aligned practice, expect a documented conversation with the patient (and family, where appropriate) covering what happened, what led up to it, and what might prevent it next time. It is also generally expected that staff will debrief among themselves. Chart that the debrief happened, who participated, and anything the patient identified as a trigger or a helpful alternative for future events. This last item feeds directly into the care plan, which is where a restraint episode is supposed to offer useful changes, and/or ways to decrease the need for restraints in the future. Charting example: "1545: Restraints discontinued. Patient has been calm and cooperative x30 minutes, and is contracting for safety. Skin intact at restraint sites, circulation and sensation intact, full ROM. No injuries observed. VS WNL per flow sheet. Debrief completed with patient: states he became overwhelmed when a phone call was upsetting. Agrees to request PRN medication and staff support earlier. Changes added to care plan. Provider and oncoming nursing staff notified." The handoff piece matters as much as the note; the SBAR handoff framework is how the next shift hears about the episode before they read about it in the chart. The use of restraint is stressful for both patients and staff. Encourage everyone involved to take a break after the event has resolved, and to process it as needed.

Common Mistakes

Charting Only the Restraint

Weak: Restraints applied at 1415.
Strong: 1415: Bilateral four-point restraints applied for violent behavior: patient overturned table, continued advancing toward staff after verbal de-escalation x2 failed and refused PRN Haldol, then struck staff. Dr. Smith verbal order received 1422.

The weak version does not explain the reason for the restraint, leaving reviewers unable to determine what happened, or whether the restraint was justified. Documenting the behavior, the alternatives attempted, and the provider order for the restraint are all essential elements.

PRN Restraint Orders

Weak: Order noted: restraints PRN for agitation.
Strong: 1415: Restraints applied as per Dr. Smith's provider order for violent behavior. 1800: Patient reassessed and remains combative when approached. Dr. Smith contacted, gave order for renewal of restraints.

Federal regulation prohibits standing orders or PRN orders for restraints. Each episode requires a current, time-limited order, and behavioral orders expire based on the 4/2/1-hour age tiers (4 hours for adults, 2 hours for adolescents, and 1 hour for children). If you see a PRN restraint order, clarify it with the provider.

Leaving Gaps in the Monitoring Flowsheet Without Explanation

Weak: No documentation between 1445 and 1515 (missed 1500).
Strong: 1515: Late entry. 1500 check not documented at time of care; however, patient was with 1:1 sitter continuously and charge nurse provided oversight. Patient was pulling against restraints and agitated, requiring hands-on by all staff present.

A blank interval suggests monitoring never occurred, and no reviewer will assume otherwise. If a check was missed or charted late, document the time and reason. In psychiatric settings, also document that the patient remained under continuous observation with a 1:1 sitter or safety assistant. This shows that the patient was never left unattended, even if a documentation entry was missed.

Skipping the Consult Note After an RN Face-to-Face

Weak: 1500: This RN completed a 1-hour face-to-face evaluation. Restraint continued.
Strong: 1500: This RN completed a 1-hour face-to-face evaluation, as per facility guidelines. Findings as noted in attached assessment. Dr. Smith consulted by phone at 1510: agrees with continued restraint.

When a trained RN performs the 1-hour face-to-face for violent/behavioral restraint, regulations require that the attending physician or another licensed practitioner is contacted as soon as possible afterwards. An evaluation note without the consult note creates a documentation gap, even if the evaluation itself was timely.

Ending the Chart at the Last Monitoring Check

Weak: 1545: Patient calm. (No further restraint entries.)
Strong: 1545: Restraints discontinued after 30 minutes of calm, cooperative behavior, and contracting for safety. Serial release of restraints performed. Patient remained calm and cooperative throughout the process. Skin intact, circulation and sensation intact, full ROM, no injuries noted. Debrief completed with patient; triggers and preferred alternatives added to care plan.

Discontinuation is a required part of the episode record: document the release time, condition (mental and physical) at release, injury check, and the debrief. A restraint record that simply stops leaves the reviewer guessing when and how the episode ended. The debrief is the element that is most often omitted from charts, even though most facilities require it.

Case Example

MarcusAge 32 — Acute psychosis, admitted to inpatient psychiatry (fictional scenario)
fictional patient

Scenario

Marcus is a fictional 32-year-old male admitted to the inpatient psychiatric unit for acute psychosis. At 1410, he begins pacing and yelling, throws items in his room, slams his door, and overturns a bedside table. Verbal de-escalation is attempted but unsuccessful, and he refuses an offered PRN medication. He then hits a CNA with a closed fist. Staff apply bilateral four-point restraints at 1415 while the nurse obtains an order for the restraints. He calms over the next hour, and restraints are discontinued at 1545.

Chart Entry

1410: Patient pacing and yelling after phone call. Throwing items around room, slamming door, and overturning bedside table. Also cursing at staff. Verbal de-escalation and redirection attempted multiple times by this RN, charge RN, and floor staff, but patient not responsive to this. Also offered PO lorazepam per existing order, patient refused. Behavior continued to escalate. Postured at staff and hit CNA in the face with a closed fist.
1415: Patient escorted to bed by staff, bilateral four-point restraints applied for violent behavior endangering staff. 1:1 safety assistant initiated.
1422: Dr. Smith notified, verbal order received for restraints. Will monitor according to facility guidelines.
1500: 1-hour face-to-face evaluation completed by this RN. Patient oriented x4, somewhat less agitated, but still pulling on restraints and cursing at staff. Denies pain, skin intact, circulation intact. Continued restraint warranted due to intermittent pulling and threats toward staff. Dr. Smith consulted by phone at 1510, agrees with plan. Patient remains with 1:1 sitter/safety assistant.
1545: Restraints discontinued. Patient has had 30 minutes of calm, cooperative behavior and is contracting for safety. Serial release of restraints performed. Patient maintained appropriate behavior throughout. Skin intact at restraint sites, circulation and sensation intact, full ROM, no injuries observed. Debrief completed with patient: identifies phone calls as a trigger, agrees to request staff support earlier and take PRN medication should he become upset again. Care plan updated, provider and oncoming nursing staff notified.

Key points from above chart entry

Behavior in observable terms:
The 1410 entry records what Marcus did (threw, slammed, overturned, cursed), not a label like "aggressive." The observable behavior is what justifies a behavioral restraint and everything that follows.
Alternatives before restraint:
De-escalation attempts and the refused PRN medication are charted with outcomes. "Less restrictive interventions attempted" is a required element, and this is where it is documented in the chart.
Honest order timing:
Restraints at 1415, verbal order at 1422. Emergency application of restraints before the order is received is expected; the chart shows the real sequence.
Face-to-face plus consult:
The 1500 entry documents both the RN-performed 1-hour evaluation and the 1510 provider consult. The consult note is the half that is often left out in charting.
Discontinuation and debrief:
The 1545 entry closes the episode: release rationale, condition (mental and physical) and injury check, the debrief with what the patient identified, and the care plan updated. This is the post-restraint evaluation in practice.

Pro Tips

  • The order will almost always come after the restraint, and your charting should say so: In a true emergency, restrain first and then obtain the order as soon as possible. This sequence is expected and compliant. A chart that falsely suggests the order came first lacks defensibility and credibility. Document the actual times. The honest sequence protects you; the altered one risks scrutiny during review.
  • Document the missed check and its reason: When a monitoring check is missed, document the omission, including when it occurred and the reason. Missed checks can occur, but not documenting it and the reason why it was missed can trigger a much more serious investigation.
  • Know which clock is federal and which is your facility's: The 4/2/1-hour order tiers (adult/adolescent/child), the 24-hour see-and-reassess by a provider, and the 1-hour face-to-face are federal requirements. In contrast, the every-15-minute flowsheet interval follows your facility's policy, which is based on a federal rule that allows hospitals to set their own frequency. Review your facility's restraint policy during orientation and make sure that you can locate it when needed; it is the standard against which your chart is audited, and reading it once beats any amount of guessing. Also remember the differences in psychiatric/violent restraints versus non-violent/med-surg restraints.
  • Treat the debrief as an essential part of the process, not just as more paperwork: Nurses often skip the debrief entry, yet it serves as one of the only opportunities to prevent future incidents. Document what the patient identifies as triggers for escalation and note strategies that could help earlier. Include this information in the care plan and communicate it during report. A restraint episode that does not lead to changes in the plan is likely to repeat.

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