/clinical/,/clinical/patient-safety/,/clinical/patient-safety/quality-safety/,/clinical/patient-safety/quality-safety/restraint-resources-and-tips/,/clinical/patient-safety/quality-safety/restraint-resources-and-tips/documentation/,

/clinical/patient-safety/quality-safety/restraint-resources-and-tips/documentation/

201512336

page

100

UWHC,

Nursing,Patient Care,Quality,Safety,

Clinical Hub,Patient Safety,Nursing Quality and Safety Resources,Restraint Resources and Tips

Documentation

Documentation - Clinical Hub, Patient Safety, Nursing Quality and Safety Resources, Restraint Resources and Tips

Focus

Time Frame

Non-Violent

Violent

Continuous Observation

None required

The patient in simultaneous restraint and/or seclusion (Inpatient Psychiatry only) is continually monitored:

  • Face-to-face by an assigned, trained staff member; or
  • By trained staff using both video and audio equipment

This monitoring must be completed in close proximity to the patient. (Note: Continually means ongoing without interruption.)

Patient in locked limb restraints

Components of Required 10-minute Documentation

None required

Every 10 minutes, visual checks are performed by a RN, nursing assistant (NA) or trained technician

Components of Required 1-hour Documentation

None required

  • Hourly checks are provided by a RN, NA, or trained technician to:
  • Every hour a RN assesses:
  • When monitoring and evaluation results in the need for intervention, prompt action will be taken.
    • Provide range of motion as appropriate;
    • Reposition as needed; and
    • Determine need for hygiene, food, fluids and toileting.
    • Signs of any injury associated with the application of restraint
    • Whether the restraint has been appropriately applied
    • Readiness to meet criteria for less restrictive alternatives and discontinuation.

Components of Required 2-hour Documentation

  • Every two (2) hours a RNcompletes an assessment of the patient including the following(except for elbow immobilizers and mitts):
    • Provide range of motion;
    • Reposition as needed; and
    • Determine need for hygiene, food, fluids and toileting.
    • Signs of any injury associated with the application of restraint.
    • Whether the restraint has been appropriately applied.
    • Readiness to meet criteria for less restrictive alternatives and discontinuation.
  • When monitoring and evaluation results in the need for intervention, prompt action will be taken.

None required

Components of Required 4-hour Documentation for Elbow Immobilizers and Mitts

Every four (4) hours, an assessment by a RN will be completed to include:

  • Provide range of motion.
  • Reposition as needed.
  • Determine need for hygiene, food, fluids and toileting.
  • Signs of injury associated with the application of restraint.
  • Whether the restraint has been promptly applied.
  • Readiness to meet criteria for less restrictive alternatives and discontinuation.

Not recommended for violent behavior