Use Of Restraint-Restraint Minimisation And Safe Practice Assessment Form
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1
2(Attach Label here or Complete Details)
NAME:___________________________________________________ NHI:__________
GENDER: ____
DOB:______________
AGE:______
WARD:________________
Christchurch Hospital Campus
Use of Restraint
Date: _________________Time: _________________ Location of patient: ______________
Family/Whānau consulted and informed of restraint?
Yes
No
U
Consent obtained from Child/Family/Whānau
Yes
No
(Child Health Only)
S
Restraint Minimisation and Safe Practice Assessment
E
Specify any previous history of restraint/evaluation episodes to inform management for this episode?
O
Specify any underlying causes, triggers or unmet needs thought to be driving or contributing to the
relevant behaviour:
F
Specify restraint free interventions and/or de-escalation attempted prior to the use of restraint?
R
Specify the rationale for restraint / the harm that restraint is attempting to prevent:
E
Specify the desired outcome and criteria for restraint to end:
S
T
Specify the risks of the restraint chosen and the frequency of monitoring required:
(Note that physical restraint requires the completion of the ‘Restraint Monitoring Form’ C24033)
R
A
Disciplines consulted about this Restraint Minimisation and Safe Practice Assessment:
I
N
Restraint details
T
__________
Physical
Personal
Environmental
Specify:
Category of
(Intentional restriction of normal movement
(intentional restriction of
(intentional restriction of
restraint:
normal movement by
access to normal
by use of equipment, devices or furniture)
holding)
environment)
Staff member who initiated restraint: Name…………………………………… Designation…….. ….
Commenced: ______________
Finished: ___________
Total Time: ______
Date/Time
Date/Time
Minutes
Commenced: ______________
Finished: ___________
Total Time: ______
Date/Time
Date/Time
Minutes
Commenced: ______________
Finished: ___________
Total Time: ______
Date/Time
Date/Time
Minutes
C
Outcome
2
Was debriefing of the patient considered?
Yes
No
4
Did the patient receive a debrief?
Yes
No*
Outline why a debrief didn’t occur:
*
0
1
Did the family/whānau receive a debrief?
Yes
No
9
What impact did the use of restraint have on the patient?
0
Did the episode of restraint result in injury to the patient?
Yes*
No
*If yes complete an Incident Report Form and record number here ____________
Did the episode of restraint result in injury to staff or visitors?
Yes*
No
*If yes complete a staff accident report form (blue form)
____________
Please fax both sides of this fully completed form to the Dept of Nursing 80844
Ref 3568
Authorised by: Christchurch Hospital Campus Restraint Minimisation Group
Page 1 of 2
June 2014
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Parent category: Medical