MIME-Version: 1.0 Content-Location: file:///C:/2671C673/AP23.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Restraint Checklist

Restraint Checklist=

 

Pati= ent Name:   __________________= _______________  _________________________________

(Last name)      &n= bsp;            = ;            &n= bsp;            = ;           (First name)

 

= ______  1.      Reas= on for restraint (check all that apply):

 

= ______ a.        Patient attempting to hurt self=

 

= ______ b.        Patient attempting to hurt others

 

= ______ c.        Patient attempting to remove medically necessary devices

 

= ______  2.      Atte= mpted verbal reassurance / redirection

 

= ______  3.      Atte= mpted environmental modification (i.e., removal of patient from stressful environment)

 

= ______  4.      Type= of restraint applied (check all that apply):

 

= ______  5.      Limb restraint

= ______ a.        LUE

= ______ b.        RUE

= ______ c.        LLE

= ______ d.        RLE

 

= ______  6.      Chem= ical restraint

 

= ______ a.        Agent used  = _____________________________

 

= ______ b.        Dosage  = ;            &n= bsp;    _____________________________

 

= ______ c.        Time  &= nbsp;           &nbs= p;        _______________________= ______

 

= ______  7.      Vital signs and extremity neurovascular exam taken every 10 minutes

 

= ______  8.      Pati= ent NOT in prone position

 

= ______ a.        Supine position for transport

= ______ b.        Lateral recumbent position for transport