begg

Shift   [select name="shift1" value="07:00-15:30|07:00-19:30|15:00-23:30 |19:00-07:30|23:00-07:00"]
RESTRAINT NOTE

D:
[text name="name" default="Patient Name"]
Admitted  on: [date name="date" default="05-30-2024"]
Allergies: [checkbox="allergy" value="NKDA|(enter    allergy)"]
Observation level: [select name="obs" value="Q5|Q1:1|Q15|Q30"]
Medications given [checkbox name="medications" value="Lorazepam  1mg  PO| Lorazepam 1mg IM| Lorazepam 2mg PO| Lorazepam 2mg IM| Haldol 5mg PO| Hadol 5mg IM| Haldol 10mg PO| Haldol    10mg    IM| Benadryl 50mg  PO|Benadryl  50mg IM|Zyprexa 10mg IM|Thorazine  25mg  IM|Geodon 20mg IM| Cogentin    1mg IM| Prolixin 2.5mg IM| Prolixin 5mg PO| Thorazine 100mg PO| Thorazine 50mg PO| Igalmi  180MCG SUBLingual| Igalmi   120MCG SUBLingual| Zydis  10mg Oromucosal"]
Special Precautions: [checkbox name="precaution" value="Aggressive  Behavior | Seizure Precuation | Fall Risk | Sexually Inappropriate | Elopement  Risk | Pregnant | Red Risk"]    
BMI:[text name="bmi" default="BMI"]

A
[textarea name="reason1" default="Rationale for use of Seclusion and or Restraint"].
Methods used to avoid [checkbox name="SR1" value="Restraint|Seclusion "] were ineffective. Pt remains to be a danger to [checkbox name="danger" value="self| others | self and others"].  
Sufficient staff was present. Pt was debriefed about the reason for the use of [checkbox name="SR2" value="Restraint | Seclusion"], and the behavioral criteria for release.
Pt was placed safely on [checkbox name="SR3" value="Manual hold| Chair    Restraint| Seclusion"]at [text name="T1" default="TIME"]; [checkbox name="SR4" value="Chair Restraint| Seclusion"] at [text name="T2" default="TIME"] using CPI approved techniques.  
All dangerous items were removed from pt. [checkbox name="injury" value="No injury to patient| state whether there was an injury sustained--------"].
[text name="t4" default="TIME"] Dr was notified, and ordered [checkbox name="medications"].
Pt remains aggressive and threatening while restrained.