Incident Reports and Physical Intervention Reports must be completed and submitted to a supervisor as soon as possible but not later than the end of the shift in which the incident takes place. The report must then be processed according to the procedures at each campus.

Documenting Physical Interventions

1. Physical Intervention Reports
Every physical intervention with a student, including holds and restraints, requires a Physical Intervention Report form to be completed by the staff member who initiated the restraint.

Documentation for the continuous monitoring of a restraint and the 15 minute assessments of a restraint will also be made in the appropriate section on the Physical Intervention Form, not in the chart progress notes. If the restraint is continued for more than 2 hours, an additional PI form must be attached for documentation of the 15 minute assessments.

Physical Intervention Reports are reviewed daily by clinicians, nursing and administrative staff

2. Progress Notes
The supervisor on duty, or the LP who ordered the restraint, if he/she is on site, must write a progress note in the student’s case record that fully describes the incident, the reasons why a less intrusive measure was not justified or was ineffective, the process of reassessment and an explanation of how the child’s rights were maintained. The progress note will also concisely describe the final progression at the end of the restraint, time the restraint ended, student behavior and the processing of the restraint with the student, the student’s return to program or to a Time Out.

3. Written Approval of Verbal LP Orders for Restraint
within 72 Hours
If an LP orders a restraint, or the continuation of a restraint, by telephone, and the supervisor on duty writes the progress note, the LP who ordered the restraint will sign and date the progress note, with his/her title, in the margin beside the note, within 72 hours of the time he/she gave the order to restrain/continue the restraint.

In these instances, as long as the LP agrees that the supervisor’s progress note is accurate, it is not necessary for the LP to write an additional note. He/she will simply sign and date the supervisor’s note in the margin beside the note.

In the event that the LP does not believe the supervisor’s note to he accurate, he/she will discuss the differences with the supervisor and a program administrator. If any corrections are necessary, they will be explained in a progress note, and a final, accurate note will be made. The Physical Intervention report will also he checked for accuracy and corrections made and initialed as necessary.