Resource Manual For Quality Indicators In - Department of Health

Sample data collection for Indicator 3 - use of physical restraint Appendix 1
• For the new comment (Indicate the total number of residents who were restrained
at any of the audits) a list of the people restrained at any audit will also be
required. Any people not previously on this list for the relevant quarter will need to
be added at each audit and the total people on the list counted for the new
comment.
Tables for Data Reporting Sheet
Table A: Number of uses of all physical restraint as per Part A definition
Total number of uses
of physical restraint as
per definition A from
three observation
audits on each
observation day
Observation
Day 1
Observation
Day 2
Observation
Day 3
Total for
all 3
observation
days
From Box 1 From Box 2 From Box 3 Box 1 + 2 + 3
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.
Add boxes 7, 8, 9 for requests by resident.
Add boxes 10, 11, 12 for requests by family/advocate
• 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
Total number of uses
of physical restraint as
per list B from three
observation audits on
each observation day
Observation
Day 1
Observation
Day 2
Observation
Day 3
Total for
all 3
observation
days
From Box 4 From Box 5 From Box 6 Box 4 + 5 + 6
Comments
• REQUIRED if applicable - Number of the restraint uses in this Total that were
specifically requested by the resident or the resident’s family/
Add boxes 13, 14, 15 for requests by resident.
Add boxes 16, 17, 18 for requests by family/advocate
• OPTIONAL – any other comments
26