This column is devoted to restraint and seclusion documentation; it provides support for, and a tool for, 100% review of patients in restraints and/or seclusion.
The Joint Commission and CMS have a common goal of reducing the use of restraints and seclusion in hospitals. Hospitals have come a long way in meeting this goal, and requirements for improvement (RFI) usually are received because of poor documentation in the medical record. Generally, recommendations result from lack of physician orders, physicians not seeing patients on-site, incomplete orders as to the reason for restraints and/or seclusion, and care plans not including the goal to remove patients from restraints and/or seclusion.
Often during surveys, there will be no patients in restraints or seclusion and the surveyors will ask for closed records to review. Once the medical record is closed, little can be done to correct documentation. Therefore, a solid open record review is essential to avoid recommendations.
A process for reviews
Review of open records of patients in restraints and/or seclusion can be performed in several ways. Of utmost importance is the development of a method to identify patients in restraints and seclusion on a daily basis, and to review new and recurring patients until they are discharged. For example:
1.Nurses, clinical documentation specialists, and tracer teams (plus others?) can review medical records each day to ensure documentation compliance
2.If the hospital has an EMR, HIM staff can review open records online to identify discrepancies in documentation and report back to each unit
3.HIM and IT staff can collaborate to develop a method of importing information directly from the EMR to identify documentation errors
Any of these methods should eliminate errors as long as they are corrected as soon as possible before patients are discharged.
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