Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 3
Subtitle 21 - MENTAL HYGIENE REGULATIONS
Chapter 10.21.12 - Use of Quiet Room and Use of Restraint
Section 10.21.12.10 - Documentation
Universal Citation: MD Code Reg 10.21.12.10
Current through Register Vol. 51, No. 19, September 20, 2024
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.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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