Prior to or immediately after applying restraints, the nurse must document the use of restraints in the medical record. Which item is not required in the documentation for this client?
1. Need for restraint was made clear to client and/or support people
2. Why the restraint was considered necessary
3. Type of restraint used
4. Health care provider's order for use of restraints
Correct Answer: 4
The health care provider must write the order for the use of restraints, and cannot provide a verbal or telephone order. The nurse should document the explanation provided to the client and/or support people, why the restraint was needed, and the type of restraint used.
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