TITLE: GUIDELINE FOR RESTRAINT OBSERVATION RECORD   Med Red # 1241

PURPOSE: This Restraint Observation Record is used for restraint orders harmful to self or others by removing medical devices or cannot follow commands.  Documentation is completed by the use of codes. Please refer to the key for the appropriate symbols.

When a patient’s assessment does not meet the predetermined criteria, ie. circulation assessment (Circulation Standard) an asterisk (*) is used and a focus note is required explaining the change in condition, interventions and outcome. Any change in condition or status since the last assessment requires a focus note.

INSTRUCTIONS:

Page 1

1. Affix patient identification label.
2. Write in today's date.
3. Write in initial MD order date/time.
4. Write in the 24 hour expire date and time.
5. Write in the Physician team or MD name and pager number
6. Write in RN’s initial assessment prior to use of restraints.  Check all that applies and write in additional information that may be needed.
7. Write in the less restrictive alternative to restraints that were attempted. Check all that applies and write in additional information that may be needed.
8. Write in patients response to alternatives tried.  Document a focus note if needed.
9. Write in behaviors resulting in patient being restrained.  Check all that applies and write in additional information that may be needed.
10. Write in all the restraints ordered and that are being used. Check all that applies.
11. Prior to applying restraints, RN is to education patient/significant other in restraint alternatives, reasons for restraints and expected behavior prior to release of restraints.  Check on all that applies.
12.  After immediate application of restraints, the RN completes an immediate assessment and documents by checking on all that applies.
13. When discontinuing the restraints, the restraint order or changing to another type of restraint order, write in time restraints/form is being discontinued. Check all that apply.
14. RN is to sign , date and time when restraints are discontinued.

Page 2.

1.      Affix a patient identification label.

2.      Write in the date on top of form

3.      Military time is in far left column indicating the time and row to document.

4.      Initials are written in the initial column with initials and signature/title written on the bottom of the page.  If more signature lines needed use page 3.

5.      Unlicensed assistive  personnel (UAP) may observe and monitor  behavior,  circulation status for color, respiratory status and skin integrity every 60 minutes, prn and reporting any unusual appearance to the RN for a further assessment.

6.      UAPs are to document using the code at the bottom of the page in the appropriate time row and monitoring column.

7.      Vital signs are to be recorded every 2 hours on the patients 24 hour flowsheet.

8.      RNs are to assess and document mental status, hydration, nutrition, circulatory status and toilet/comfort a minimum of every 2 hours.

9.      RNs are to initials the appropriate row corresponding to the time of the assessment using the code related to the assessment.

Page 3

10.  RNs are to use page 3 for any additional information required for the restraints and patient assessments related to restraints.

11.  Initials, signature and title and print name is written on the bottom of the form.

RESOURCE PERSON(S):

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