S & R 2023

SHIFT[select name="variable_1" value="0700-1500|1500-2330|1900-0700|0700-1930|1930-2330|2330-0700"]
Patient [textarea name="NAME" default="NAME"].
Patient admitted on [date name="variable_1" default="08-11-2023"] for [textarea name="variable_1" default="Diagnosis"]. 
Patient has  [checkbox name="variable_5" value="no known food and drug allergy|no known food allergy| ALLERGIC TO(List meds)|NO known drug allergy"]
He is on 
[checkbox name="variable_1" value="Q5|1:1|Q15|Q30|red risk|1:1 when using the bathroom|1:1 when eating||due to (enter reason)"] for level of safety, per MD orders. 
[checkbox name="variable_3" value="He/She is on court cont until|He/She is under petition court date| PATIENT L2K was certified on  DATE TIME"].. 
Patients's current BMI is [text name="variable_1" default="enter BMI"]. 
Patient is currently on follwoing medications: [textarea name="variable_12" default="ENTER MEDS: Haldol 10mg PO BID for psychosis"]
[textarea name="variable_4" default="enter presenting problem/ what happened"]
[textarea name="variable_5" default=" ENTER Rationale for use of Seclusion and or Restraint "]. 
Methods used such as [checklist name="variable_12" value="ventillation of feelings|verbal reasssurance/ redirection|1:1 interaction with staff|reduction in stimuli|environmental change|limit setting|timeout"]to avoid seclusion and or restraints were ineffective. Patient remains to be a danger to self and or others. 
Sufficient staff was present. Patient was debriefed about the reason for the use of [select name="variable_6" value="Manula Hold|Seclusion|Chairt Restraint"], and the behavioral criteria for release.
 Patient was placed safely on[select name="variable_7" value="Manula Hold|Seclusion|Chairt Restraint"] using CPI approved techniques at [text name="variable_8" default="enter time"]
 
 Patient was placed safely on manual hold using CPI approved techniques at [text name="variable_9" default="enter time"] and was safely restrained in the chair at [text name="variable_10" default="ENTER TIME"]
 
All dangerous items were removed from patient.  Staff ensured patient is in optimal position, sitting upright, head unrestricted maintaining patent airway, to minimize potential medical complications.
[select name="variable_14" value="Patient had no visible injury|patient sustained injury(state here"].
At [text name="variable_11" default="ENTER time"] Dr was notified, (and any orders ----------).
Patient remains aggressive and threatening while restrained. 
[select name="variable_13" value="Dr completed face-to face evaluation within an hour|QRN completed the face-to-face evaluation within an hour"] 
Staff was debriefed.
Patient was offered fluids and snacks; toileting and comfort measures, skin integrity check; restraint, circulation and respiratory status check every 15 minutes, were documented by staff on the observation form.
Range of motion exercise was offered to patient every hour but patient refused. Patient  refused vital signs at (enter times of refusal).
(ENTER TIME) Patient was calm/no longer danger to self or others. Patient was released the earliest possible time. Patient was debriefed about the reason for ([select name="variable_15" value="Manual Hold|Chair restraint |Seclusion"], and the criteria for release. 
 Patient acknowledged debriefing. 
 Patient [select name="variable_16" value="is currently supported by PBSP, updated (enter date)|does not have a PBSP"]. 
 Request for Psychology consult was completed, and interventions reported to Treatment Team members. Environmental rounds completed to ensure safe and clutter free environment.
 P:
Will continue observation level as ordered. 
Will continue with orders by MD and implement interventions on treatment plan.
Will monitor for any changes in behavior and evaluate effectiveness of medications, adverse reactions, or side effects.
Endorsed to next shift.
RN NAME, TITLE