Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Posted: 9/2/2020
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Release Notes:
Data Element
Version 2020B2

Name:Minutes of Physical Restraint
Collected For: HBIPS-2
Definition:The total minutes recorded in the medical record that a patient was maintained in Event Type 1 (physical restraint(s)) for the associated Event Date.
Question:What was the total number of minutes recorded in the medical record that the patient was maintained in Event Type 1 (physical restraint) for the Event Date?
Format:
Length:4 or UTD
Type:Alphanumeric
Occurs:1
Allowable Values:


1-1440
UTD= Unable to Determine
Notes for Abstraction: Event Type 1 (physical restraint(s)) should be reported in whole minutes. Events less than or equal to 60 seconds should be reported as 1 minute (i.e., event duration of 2 minutes 5 seconds is reported as 3 minutes).

For each patient enter the Minutes of Physical Restraint that corresponds with the Event Date and Event Type.

If a patient is in Event Type 1 (physical restraint(s)) and then changed to Event Type 2 (seclusion), the time for Event Type 1 (physical restraint(s)) STOPS. The initiation of Event Type 2 (seclusion) stops the time for Event Type 1 (physical restraint(s)).

If a patient is in Event Type 1 (physical restraint(s)) and Event Type 2 (seclusion) at the same time, the time should be counted as Minutes of Physical Restraint. Time in physical restraints supersedes time in seclusion.

Select unable to determine when either the start or stop time OR the total number of minutes of Event Type 1 (physical restraint) event is missing from the medical record and the total Minutes of Physical Restraint can not be calculated for the associated Event Date.

See the guidelines for abstraction for definition of an Event Type 1 (physical restraint).

When an Event Type 1 (physical restraint) starts at school or during an off-campus outing; this event should be reported.

Suggested Data Sources:
  • Licensed independent practitioner orders
  • Nursing flow sheet
  • Nursing notes
  • Observation sheets
  • Physician orders
  • Progress notes
  • Psychiatrist notes
  • Restraint monitoring form
  • Therapist notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
A physical restraint is any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely when it is used as a restriction to manage a patient's behavior or restrict the patient's freedom of movement and is not a standard treatment for the patient's medical or psychiatric condition.¹

Examples of physical restraint includes but is not limited to::
  • 2 point restraint
  • 4 point restraint
  • 5 point restraint
  • Body nets
  • Mittens to prevent intentional self-harm
  • Wrist-to-waist restraints
  • Soft wrist restraints
  • Manual holds
  • Stapling
  • Jarvis
  • Leather restraints
  • Devices that serve multiple purposes such as a Geri chair or side rails, when they have the effect of restricting a patient's movement and cannot be easily removed by the patient, constitute a restraint. ²

¹,²,³ 42 CFR Part 482, Medicare and Medicaid Programs; Hospital Conditions of Participation: Patient's Rights

  • Devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets
  • Methods that involve the physical holding of a patient to conduct routine physical examinations, tests, or medication administration
  • Methods that protect a patient from falling out of bed
  • Methods that permit the patient to participate in activities without the risk of physical harm (does not include a physical escort)³
  • Restraint uses that are forensic or correctional restrictions applied and used by outside law enforcement
  • Restraint uses that are forensic or correctional restrictions applied and used by designated hospital security personnel to transport the patient to court off the locked unit

Minutes of Physical Restraint
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Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

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