Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 3
Subtitle 21 - MENTAL HYGIENE REGULATIONS
Chapter 10.21.13 - Use of Quiet Room and Use of Seclusion
Section 10.21.13.08 - Documentation
Universal Citation: MD Code Reg 10.21.13.08
Current through Register Vol. 51, No. 19, September 20, 2024
A. Seclusion Orders. A physician shall:
(1) To initiate
the use of seclusion:
(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 seclusion; 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
seclusion:
(a) The date and time that the
order was written;
(b) The maximum
duration of seclusion from the time that the seclusion was initiated;
(c) The specific rationale for
seclusion;
(d) Special precautions,
if any, to safeguard the patient;
(e) The physician's signature; and
(f) 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 seclusion in the patient's medical record; and
(2) Include in the documentation the
following information:
(a) A description of
the specific behavior leading to seclusion;
(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 seclusion, and the
circumstances while secluding the patient;
(d) The readily observable physical condition
of the patient;
(e) The date and
time of the seclusion 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 seclusion.
C. While a patient is in seclusion, staff shall document in the patient's medical record the clinical interventions employed, including those listed in Regulation .06 of this chapter.
D. Release from Seclusion.
(1) When a physician clinically determines
that a patient is to be released from seclusion, 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 seclusion 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 seclusion in the patient's
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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