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Seclusion Flow Sheet by eYhL5doH

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									Form 260 Org: 03/09 Rev: 0409, 04/11                                                        Page 1 of 1



                                          SECLUSION FLOW SHEET

Consumer Name:_________________________________________________ DOB:___________________

Date: _________Time: _______           Behavior Exhibited: _______________________________________

________________________________________________________________________________________

Alternative Measures Attempted: [ ]Orientation [ ]Limit Setting [ ]Needs Addressed [ ]Diversion
[ ]Medication:Specify:______________________________________________________________________

Time: _____ Physician’s Order: Dr ___________________ Time Placed In: ________

Time: _____ Physician’s Visit (Must be within 1 hour of start time.) Signature:______________________

Hazardous Articles removed by ______         Restraints Are Prohibited While Consumer is in Seclusion

BEHAVIORAL CODES: A=beating door; B=yelling; C=combative; D=crying; E=cursing; F=threatening;
G=pacing; H=disrobing; I=singing; J=laughing; K=mumbling; M=standing still; N=lying/sitting; O=Quiet;
P=sleeping;

 TIME      PULSE       B/P       RESP      CIRC    TOILET   INTAKE      BEHAVIORAL CODE           INITIAL




1HR




2HR




3HR




4HR


                                                  TERMINATION

Time Seclusion Terminated: __________ Initial: ______              Total Time In Seclusion: _________
Criteria: [ ] Absence of threatening behavior X 15 minutes
[ ] Absence of self-injurious behavior and threats x 15 minutes And [ ] Agrees to contain behavior
Or      [ ] Asleep     Time: ______       Initial: ______


INITIAL                      NAME (PRINTED)                                   SIGNATURE

								
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