US · guidance
CMS SOM App. A, Tag A-0187
[When restraint or seclusion is used, there must be documentation in the patient's medical record
of the following:]
§482.13(e)(16)(iv) - The patient's condition or symptom(s) that warranted the use of the restraint
or seclusion.
Interpretive Guidelines §482.13(e)(16)(iv)
A comprehensive, individualized patient assessment is necessary to identify the most appropriate
intervention to effectively manage a patient’s condition or symptom(s). When using a restraint or
seclusion intervention, the patient’s condition or symptom(s) must be identified and documented in the
patient’s medical record.
Survey Procedures §482.13(e)(16)(iv):
Does the patient’s medical record include descriptions of the patient’s condition or symptom(s) that
warranted the use of restraint or seclusion?
History
Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
47b514fa8e2cebc741652b6d7e9be95771520eb11a09c66c4f4f26c52c6381e7
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