RESTRAINT AUDIT TOOL C NON-BEHAVIORAL MANAGEMENT by dfgh4bnmu

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									                                    RESTRAINT AUDIT TOOL – NON-BEHAVIORAL MANAGEMENT
                                                                                                                     Fax completed form to: April Bowles at 982-6838 or mail to box 800476
UNIT:                                                                                                                                         Y=Yes N-No         N/A=Not applicable
                             CHART 1       CHART 2       CHART 3            CHART 4            CHART 5            CHART 6         CHART 7         CHART 8      CHART 9      CHART 10
Medical Record Number:

Admit Date:

Audit Date:

Reviewer(s):

           NON-BEHAVIORAL MANAGEMENT                                           CHART:             1      2       3        4   5    6    7     8     9    10        COMMENTS

Alternatives that were tried are documented.

Patient/family education provided and documented.

The specific behavior necessitating restraint is documented.

There is an MD order based on an examination of the patient entered into the
medical record within 24 hours of the initiation of restraint.

MD order for restraints exists and is current (must be renewed every 24 hours).

A face-to-face evaluation by the MD is done within 24 hours of the order.

Safety checks were done and documented every hour.


Behavior and interventions are documented every 2 hours.

Release criteria are documented by the nurse every 2 hours.

The care plan reflects the current restraint status.

Restraints are discontinued if criteria is met.


090808 REV 10/10   NOT A CHART DOCUMENT           To reorder, log onto http://www.virginia.edu/uvaprint/HSC/hs_forms.pl                                                    PAGE 1 OF 2
                    RESTRAINT AUDIT TOOL – FOR SECLUSION AND BEHAVIORAL RESTRAINTS ONLY
                                                                                                              Fax completed form to: April Bowles at 982-6838 or mail to box 800476
UNIT:                                                                                                                                  Y=Yes N-No         N/A=Not applicable
                              CHART 1         CHART 2        CHART 3         CHART 4            CHART 5   CHART 6         CHART 7          CHART 8      CHART 9      CHART 10
Medical Record Number:

Admit Date:

Audit Date:

Reviewer(s):

FOR SECLUSION & BEHAVIORAL RESTRAINTS ONLY CHART: 1                                                   2   3     4     5     6    7     8     9    10        COMMENTS
RN initial assessment after restraint application indicates proper and safe application                                                                INDICATE DURATION OF
and patient response.                                                       (Beh. Mgt. FS)                                                             EPISODE
Type of restraint chosen documented by MD.                                (Restr. Prog. Note)
                                                                                                                                                            Hours        Minutes
Reason for applying restraint documented by MD.                           (Restr. Prog. Note)
Face-to-face evaluation documented by MD or RN within 1 hour includes an evaluation
of the patient’s immediate situation, reaction to the intervention, medical and behavioral
condition, the need to continue or terminate the restraint or seclusion. (Restr. Prog. Note)
Order renewed every 4 hours
New order entered every 8 hours
Patient monitored 1:1 or constant observation                                 (Beh. Mgt. FS)
Assessment includes need to continue restraints every 2 hours.                (Beh. Mgt. FS)
Hydration, nutrition and elimination needs were addressed every 2 hours. (Beh. Mgt. FS)
Skin integrity and limb circulation were addressed every 2 hours.             (Beh. Mgt. FS)
If patient in restraints for 12 hours or experiences 2 or more separate episodes within
12 hours, unit manager was contacted.                                        (Beh. Mgt. FS)
Pre-existing medical conditions or any physical disabilities and limitations that would
place the patient at greater risk during restraint or seclusion is assessed and
documented.                                                            (H&P and Prog. Note)
Any history of sexual or any physical abuse that would place the patient
at greater psychological risk during restraint or seclusion is assessed
and documented.                                                       (H&P and Prog. Note)
Patient’s family is contacted to inform them of the restraint or seclusion episode, if
applicable.
Evidence of short debriefing with patient/family after discontinuation.
                                                                   (Beh. Mgt. FS, Prog. Note)
Restraints are discontinued if criteria are met.                                                                                                                    PAGE 2 OF 2

								
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