Use Of Restraint-Restraint Minimisation And Safe Practice Assessment Form (Page 2 of 2) in pdf

Use Of Restraint-Restraint Minimisation And Safe Practice Assessment Form Page 2

Evaluation of the Episode

(Attach Label here or Complete Details)

of Restraint Use

NAME:___________________________________________________ NHI:__________

Personnel involved in this evaluation

GENDER: ____

DOB:______________

AGE:______

WARD:________________

(staff name & designation, patient or

family/whānau involved)

Name

Designation

Name

Designation

Was the use of restraint clinically justified?

Yes

Was the type of restraint used approved for use? *If no complete an incident form

Yes

No*

and record the number here ____________

Was the desired outcome achieved?

Yes

Was the patient monitored?

Yes

Any suggested changes to the patient’s treatment/crisis plan/plan of care including the need for

advocacy and support?

Future options to avoid restraint, utilise a less restrictive option, or lessen the amount of time restraint is

used?

Any general ideas on how restraint minimisation should be practised/taught?

For completion by Line Manager who assisted in evaluation

Comment if the restraint was appropriate and the restraint minimisation policy was followed

_____________________________________

___________________________

__________________

Signed (manager)

Designation:

Date

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 2 of 2

June 2014

Use Of Restraint-Restraint Minimisation And Safe Practice Assessment Form Page 2