Which is part of restraint documentation after removal?

• A. Delete any notes after observation
• B. Only document if problem occurs
• C. Document only the time restraints were removed
• D. Document the restraint assessment

Answer: (D)

Restraint documentation after removal focuses on confirming the patient’s safety and condition has been re-evaluated. The note should capture a full restraint assessment: current mental status and behavior, pain level, vital signs, neurovascular checks and range of motion of the previously restrained limbs, skin integrity and any injuries, and the patient’s tolerance of removal. It also includes what observations were made, any ongoing risks, and the plan for monitoring or whether restraints may be needed again or alternatives tried. This thorough documentation provides a legal, complete record and supports continuity of care; simply deleting notes, documenting only if a problem occurs, or recording only the removal time would omit critical information about safety and ongoing needs.