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Restraint assessment form

Restraint assessment form 2025

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The document outlines the procedures and guidelines for the monitoring and documentation of restraint and seclusion in a behavioral health setting. It includes details on the initiation of restraints, reasons for their use, required documentation, assessment intervals, and specific protocols for different age groups. The form is designed to ensure patient safety and compliance with legal standards while providing clear instructions for healthcare providers.

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Click ‘Get Form’ to open the restraint assessment form in the editor.
Begin by filling in the 'Initiation of Restraints' section. Enter the date and time when restraints were initiated, along with the reason for restraint, ensuring it aligns with behavioral criteria.
Document family notifications regarding restraint use. Use the provided fields to note down who was informed, along with date and initials.
In the 'Type of Restraint Key', select and document the type of restraint used. Ensure you follow age-specific guidelines for reordering restraints as indicated.
Complete monitoring sections every 15 minutes, documenting physical and psychological responses, orientation status, and readiness for release. Use checkmarks and stars appropriately to indicate findings.
Finally, ensure that all discontinuation of restraints is documented accurately with date/time and initials in the designated area.

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What assessment is needed for restraints?

Assessing the patients behavior To establish the patients behavioral baseline, assess his or her mental status, mood, and behavioral control. This allows clinicians to later determine how the patient is tolerating restraint and helps ensure restraint will be discontinued as soon as clinically indicated.

What is an example of a state of restraint?

Examples of Physical Restraint Practices Placing a chair close to a wall, heavy table, or other barrier to prevent rising. Using a concave mattress that the patient cannot get out of. Tucking in a sheet tightly so it prevents movement; fastening fabric or clothing in such a way that freedom of movement is restricted.

What are 5 examples of restraint?

Some examples of physical restraints include: Lap belts. Recliners that lean back, preventing easy movement. Side rails. Concave mattresses that prevent the patient from getting out of bed. Vests or belts on the wrists, pelvis, or waist that restrict movement. Trays or other devices that can prevent rising from a chair.

What are the 3 types of restraints?

There are three types of restraints: physical, chemical and environmental. Physical restraints limit a patients movement. Chemical restraints are any form of psychoactive medication used not to treat illness, but to intentionally inhibit a particular behaviour or movement.

What documentation is required for restraints?

The flowsheet should include the following: patient behavior that indicates the continued need for restraints patients mental status, including orientation number and type of restraints used and where theyre placed condition of extremities, includ- ing circulation and sensation extremity range of motion

Key Facts about the Restraint/Seclusion Monitoring Record

Two-page documentation form

Time block usage

Required data elements

Family notification protocol

Restraint order frequency

Documentation keys

Monitoring requirements

Two-page documentation form

The Restraint/Seclusion Monitoring and Reassessment Record is a two-page form specifically designed for documenting restraint assessment and intervention criteria when the reason is behavioral.

Time block usage

A new form must be used for each four-hour time block, with appropriate dating in the provided blanks.

Required data elements

The date and time of restraint initiation, as well as the reason for restraint, are required data elements that must be carried forward to subsequent forms.

Family notification protocol

Family members must be informed of the restraint initiation, and this should be documented with date, time, and initials by the notifying individual.

Restraint order frequency

A restraint order is required every four hours for adults, every two hours for children aged 9-17, and every hour for children under age 9.

Documentation keys

The documentation key includes symbols indicating normal findings (checkmark), significant findings (star), and ongoing significant findings (arrow) that require notes in the Exceptional Observations section.

Monitoring requirements

Every 15 minutes, assessments related to appropriateness of restraint, physical and psychological response, orientation/mental status, readiness for release, and neurovascular status must be documented.

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