may 2024 SR

CAUTION: This page needs to be reviewed and categorized.
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. 

[select name="1hr" value="Dr completed face-to face evaluation within an hour. | QRN completed the face-to-face evaluation within an hour. Refer to QRN face to face evaluation form."]  
Staff debriefed.
Pt was checked every 15 min for mental and respiratory status, circulation, skin integrity, including placement of restraints. Fluids, toileting and comfort measures were offered every 15 minutes. 
Range of motion: [checkbox    name="ROM" value="Range of motion was performed every 1 hr for 10 min.| Patient    Refused. |N/A"]
Vital Signs: vital signs every 15 mins for the first hour after application. Then every 1 hour thereafter.  [checkbox="vs1" value="Assessed    and    documented    as    follows:    (enter    one    set    of    VS)|Attempted   and    patient    refused| N/A"]

[text name="time5" default="TIME"] Pt was calm/no longer danger to self or others. Pt was released the earliest possible time. Pt was debriefed about the reason for seclusion and restraint, and the criteria for release. 
 Pt acknowledged debriefing. 
PBSP: [select name="PBSP" value="YES|NO"]
Psychology consult was requested. 
Medical    Concerns: [checkbox name="MedicalConcern" value="No    medical    Concerns|Diabetic|Hypertensive|Hypotensive|Pregnant|Seizure|Receiving    Anti-Coagulant    Therapy |Poor    Skin    Turgor| Other"]

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.ac

[text name="RN" default="RN NAME, TITLE"]
Shift
RESTRAINT NOTE

D:

Admitted on:
Allergies:
Observation level:
Medications given
Special Precautions:
BMI:

A
.
Methods used to avoid were ineffective. Pt remains to be a danger to .
Sufficient staff was present. Pt was debriefed about the reason for the use of , and the behavioral criteria for release.
Pt was placed safely on at ; at using CPI approved techniques.
All dangerous items were removed from pt. .
Dr was notified, and ordered .
Pt remains aggressive and threatening while restrained.


Staff debriefed.
Pt was checked every 15 min for mental and respiratory status, circulation, skin integrity, including placement of restraints. Fluids, toileting and comfort measures were offered every 15 minutes.
Range of motion:
Vital Signs: vital signs every 15 mins for the first hour after application. Then every 1 hour thereafter.

Pt was calm/no longer danger to self or others. Pt was released the earliest possible time. Pt was debriefed about the reason for seclusion and restraint, and the criteria for release.
Pt acknowledged debriefing.
PBSP:
Psychology consult was requested.
Medical Concerns:

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.ac


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Sandbox Metrics: Structured Data Index 0.69, 26 form elements, 208 boilerplate words, 7 text boxes, 1 text areas, 1 dates, 13 checkboxes, 4 drop downs, 73 total clicks
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