Confidential Dhhs Restrictive Intervention Details Report - North Carolina Page 2

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North Carolina Department of Health & Human Services – Division of Mental Health/Developmental Disabilities/Substance Abuse Services
DHHS Restrictive Intervention Details Report
CONFIDENTIAL
CONFIDENTIAL
-
-
Provider Agency Name
Consumer’s Name
Consumer’s Social Security No.
INITIAL CHECK
ENDING CHECK
FOLLOW-UP CHECK
ITEM
(Prior to Intervention)
(Immediately after Intervention)
(30 minutes after Intervention)
Consciousness
Alert
Dazed
Alert
Dazed
Unconscious
Alert
Dazed
Unconscious
Please explain any
:
abnormality
Speech
Normal
Abnormal
Normal
Abnormal
Normal
Abnormal
Please explain any
:
abnormality
Breathing
Normal
Hard / Irregular
Normal
Hard / Irregular
Normal
Hard / Irregular
Please explain any
:
abnormality
Movement
Normal
Abnormal
Normal
Abnormal
Normal
Abnormal
Please explain any
:
abnormality
Skin Color
Normal
Pale
Flushed
Normal
Pale
Flushed
Normal
Pale
Flushed
Please explain any
:
abnormality
Orientation
Person
Place
Time
Person
Place
Time
Person
Place
Time
Please explain any
:
abnormality
Affect / Mood
Appropriate
Inappropriate
Appropriate
Inappropriate
Appropriate
Inappropriate
Please explain any
:
abnormality
Describe the person’s behavior after the intervention:
Was the person monitored continuously during the intervention and for 30 minutes afterward?
Yes
No
If not monitored continuously, provide an explanation:
Name/Title of persons providing monitoring (Please print):
Signature:
Date
Signature:
Date
Name/Title of staff person documenting intervention (Please print):
Signature:
Date
Confidentiality of consumer information is protected under Federal regulations, 42 CFR Part 2 and HIPAA, 45 CFR Parts 160 & 164.
DMH/DD/SAS-Community Policy Management Section – Form QM04
Effective October, 2004 – Rev. 11/18/04
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