Debriefing Form - Seclusion / Restraint For Emergency Safety Situations printable pdf download

Name of Hospital

SECLUSION / RESTRAINT

For Emergency Safety Situations

Debriefing Form

CONSUMER IDENTIFICATION

DEBRIEFING WITH CONSUMER FOLLOWING SECLUSION OR RESTRAINT (NO LONGER THAN 24 HOURS AFTER INCIDENT)

Precipitating factors:  Conflict with Peer  Environmental  Limit Setting  Conflict with Staff  Unit Rules

Other: ______________________________________________________________________________________

As evidenced by: ________________________________________________________________________________________

The following issues should be discussed with the consumer:

What led to the incident? ________________________________________________________________________________

_____________________________________________________________________________________________________

What did staff do that was helpful or not helpful prior to the incident? _______________________________________________

______________________________________________________________________________________________________

What could have been done differently before, during and after use of seclusion or restraint?

____________________________________________________________________________________________________

Did staff take care of the consumer’s physical well-being, psychological comfort and right to privacy?

_____________________________________________________________________________________________________

______________________________________________________________________________________________________

What staff actions helped the consumer gain control? ___________________________________________________________

______________________________________________________________________________________________________

How did the consumer feel after being released & is there a need for supportive counseling? _____________________________

______________________________________________________________________________________________________

How can staff better help with future instances of difficulty? ______________________________________________________

______________________________________________________________________________________________________

Treatment Team Member Signature _____________________________________ Date _____________ Time ____________

REVISIONS TO ISP or ITP PLAN TO REDUCE POSSIBILITY OF INCIDENT RECURRING

(Must be added to treatment plan in addition to noting here)

 Change medication dose/frequency

 Consultation with Psychologist

 Change type of medication

 Use of different behavioral interventions

 Other _______________________________________________________________________________________________

MD or Licensed Nurse Signature _____________________________________ Date _____________ Time _____________

NAMES OF STAFF PRESENT FOR THE DEBRIEFING WITH THE CONSUMER. (Also note any who were excused.)

Page 1 of 1 DHR DMHDDAD Policy # 3.104 Use of Seclusion or Restraint for Emergency Safety Situations in DHR Division of MHDDAD Hospitals –

Attachment C – Version 2007.12.21

Debriefing Form - Seclusion / Restraint For Emergency Safety Situations