Resource Manual For Quality Indicators In - Department of Health

Indicator 3: Incidence of use of physical restraint
Table A: Number of uses of all physical restraint as per Part A definition
Observation
Day 1
Observation
Day 2
Observation
Day 3
Total
Total number of uses of
physical restraint as per
definition A from three
observation audits on
each observation day
Comments
• REQUIRED if applicable - Number of the restraint uses in this Total that were
specifically requested by the resident or the resident’s family/advocate
for example, 12 restraint uses from total were water chair requested by family
• REQUIRED if applicable - New information - Indicate the total number of
residents who were restrained at any of the audits.
• OPTIONAL – any other comments
Table B: Number of uses of List B physical restraint observed
Observation
Day 1
Observation
Day 2
Observation
Day 3
Total
Total number of uses of
physical restraint as per
list B from three
observation audits on
each observation day
Comments
• REQUIRED if applicable - Number of the restraint uses in this Total that were
specifically requested by the resident or the resident’s family/advocate
for example, 3 restraint uses were bedrail requested by resident for security
• OPTIONAL – any other comments
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