SIDE ONE INFORMED CONSENT FOR USE OF RESTRAINTS - Med-Pass 2025

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When consent is appropriate, nursing home residents may lack the decision-making capability to voluntarily consent to the use of physical or chemical restraints. In this situation, the use of restraints should be discussed with the residents family or other surrogate decision-maker.
(b) Restraints shall only be used with a written order of a licensed healthcare practitioner acting within the scope of his or her professional licensure. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients.
Except for limited periods of time in cases of emergency, where you are in danger of harming yourself or others, the nursing staff cannot give you a drug or apply a physical restraint unless you or your representative, if you are unable, gives permission in advance for their use.
Informed consent is required prior to all non-emergent restraint use.
I have been informed of the potential benefits and risks of restraint use (as explained on the reverse) and hereby assume full liability for any adverse outcomes related to my decision. I have been afforded the opportunity to ask and receive answers to my questions.
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Obtaining informed consent in medicine is a process that should include describing the proposed intervention, emphasizing the patients role in decision-making, discussing alternatives to the proposed intervention, discussing the risks and benefits of the proposed intervention, and eliciting the patients preference,

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