322-0263 RESTRAINT SECFUSION ORDER FORM rev 04-09

RESTRAINT/SECLUSION/
PHYSICIAN ORDER SHEET
PATIENT CARE PLAN
Staffing Levels: ___ RN ___ LPN ___ AIDE ___ ER TECH ___ SECURITY
VIOLENT / SELF-DESTRUCTIVE BEHAVIOR
Date Initiated: _______________ Time Initiated: __________
Wrist Ankle Vest Pelvic Locked
Jacket Side Rails (3 or more)
Seclusion
Chemical Restraint Order: ____________________________
______________________________________________________
Age 18 or older: Order expires in 4 hours
Age 9-17: Order expires in 2 hours
Less than 9 years: Order expires in 1 hour
• Verbally contracts for safety to self / others
• Responding to redirection
Provide companionship and supervision (1:1)
Changing or eliminating bothersome treatments
Frequent reorientation to surroundings
Offering diversionary and physical activities
Bed monitoring device
Reality orientation and psychosocial interventions
Self Time Out
PLAN OF CARE FOR RESTRAINED PATIENT
REASON FOR RESTRAINT
TYPE OF RESTRAINT
TIME LIMIT DURATION
ALTERNATIVES TRIED
DISRUPTING MED / SURG TREATMENTS
Date Initiated: _______________ Time Initiated: __________
Wrist Ankle Vest Pelvic Locked
Jacket Side Rails (3 or more)
Order expires in 24 hours
RESTRAINT TO BE DISCONTINUED IF
• No longer demonstrates risk for danger to self and others
• Responding to alternatives
Scheduled checks for pain, food or comfort
Scheduled bathroom privileges
Disguise tubes and lines
Verbal reminders / de-escalation
Medications offered
Design creative alternatives:
Modify environment:
Physician (or other LIP) consulted.
Restraints are to be released every 2 hours for 15 minutes OR pressure point massage every 2 hours for 15 minutes
For Med/Surg restraint, check patient at a minimum, every 2 hours
Offered fluid/food and toileting every hour while awake
Vital signs as indicated.
Patient to be reassessed every 2 hours by RN and whenever there is a significant change in condition.
Educate patient/family on rationale and release criteria for restraints
Family notification with patient’s consent.
Violent or Self-Destructive Restraint / Seclusion
1. Face-to-face evaluation by RN within 1 hr of initiating restraint.
2. Continuous 1:1 observation with every 15 minutes documentation.
3. If seclusion / restraint lasts more than 12 hours or 2 episodes occur within 12 hours, clinical leadership will be notified.
4. Complete debriefing within 24 hours when on a psychiatric unit.
I have examined and evaluated the patient for their reaction to the intervention, current medical and behavioral condition and
concur with the need FOR restraint or seclusion.
______________________________
DATE/TIME OF TELEPHONE ORDER
______________________________________________________
NAME OF DOCTOR / RN SIGNATURE
______________________________
______________________________________________________
DATE/TIME
PHYSICIAN SIGNATURE
WHITE - CHART YELLOW - NURSE MANAGER
FORM 322-0263 Rev. 4/09 (PART 1 OF 2)
RESTRAINT/SECLUSION/PHYSICIAN ORDER SHEET PATIENT CARE PLAN

GUIDELINES FOR REDUCTION OF RESTRAINT/SECLUSION
ALTERNATIVE INTERVENTIONS
RESTRAINT/SECLUSION
INTERVENTIONS
Wandering Mentally Impaired
• Buddy system: family, volunteer, nursing staff.
• Patient alarm device.
• Activate IDT, review/modify plan of care.
• Assign diversional activity.
• Safety belt.
• Vest restraint.
• Wrist restraints (only if removing essential, invasive
tubing, IV, etc., or attempting to mutilate self).
• Assess for pain, hunger, thirst, need to use
the bathroom.
• Place near nursing station.
• Offer prn medication, as prescribed.
Unconscious, attempting to remove medical devices.
• Buddy system: family, volunteer.
• Cover invasive tubing, IVs, etc. with gauze.
• Mitt restraint.
• Wrist restraint.
• Sedation as ordered.
Uncontrollable hyper-motor-activity, preventing implementation of clinical care.
• Temporary holding for completion of procedure.
• Scheduled exercise/toileting/activity.
• Meaning activity, use personal stereo (walkman)
with patient’s favorite music.
• Elbow restraint.
• Mummy restraint.
• Wrist restraint (if causing injury to self).
• Offer prn medication, as prescribed.
• Diversional activity, place soft items in both hands.
Intrusive behavior/physical aggression to self or others.
• Therapeutic conversation.
• Remove excessive stimulation.
• 15 minute self time out.
• Verbal interaction/redirecting.
• Seclusion.
• Wrist restraint.
• Vest restraint.
• Locked restraint.
• PRN medication, as prescribed.
This is not meant to exhaust all possibilities, but to act as a guide for potential behavior problems, alternative
interventions, and appropriate choices of least to most restrictive restraint/seclusion interventions.

RESTRAINT/SECLUSION/
PHYSICIAN ORDER SHEET
PATIENT CARE PLAN
Staffing Levels: ___ RN ___ LPN ___ AIDE ___ ER TECH ___ SECURITY
VIOLENT / SELF-DESTRUCTIVE BEHAVIOR
Date Initiated: _______________ Time Initiated: __________
Age 18 or older: Order expires in 4 hours
Age 9-17: Order expires in 2 hours
Less than 9 years: Order expires in 1 hour
• Verbally contracts for safety to self / others
• Responding to redirection
RESTRAINT REVIEW SECTION
Provide companionship and supervision (1:1)
Changing or eliminating bothersome treatments
Frequent reorientation to surroundings
Offering diversionary and physical activities
Bed monitoring device
Reality orientation and psychosocial interventions
Self Time Out
YES NO
Alternatives Tried / Documented
Patient / Family Educated
Code Grey Required
Patient Injury
Staff Injury
Close Watch Completed
Interdisciplinary Progress Notes
Completed
Restraint Initiated by: ________________________________
Time Removed: _______________ Length (hrs): __________
Review Section completed by: ________________________
REASON FOR RESTRAINT
TIME LIMIT DURATION
ALTERNATIVES TRIED
DISRUPTING MED / SURG TREATMENTS
Date Initiated: _______________ Time Initiated: __________
TYPE OF RESTRAINT
Wrist Ankle Vest Pelvic Locked
Jacket Side Rails (3 or more)
Wrist Ankle Vest Pelvic Locked
Seclusion
Jacket Side Rails (3 or more)
Chemical Restraint Order: ____________________________
______________________________________________________
Order expires in 24 hours
RESTRAINT TO BE DISCONTINUED IF
• No longer demonstrates risk for danger to self and others
• Responding to alternatives
Scheduled checks for pain, food or comfort
Scheduled bathroom privileges
Disguise tubes and lines
Verbal reminders / de-escalation
Medications offered
Design creative alternatives:
Modify environment:
UNIT ER Laulima Hale Ho‘ola
CCU Medical OB
CV Med/Surg Other ____________
COMPLETE THIS BOX FOR VIOLENT
OR SELF-DESTRUCTIVE BEHAVIOR YES NO
1 hr face-to-face assessment by LP or RN
Staff participating documented in
Medical Record
Debriefing documentation complete
(Behavioral Health department only)
Clinical leadership notified if >12 hrs
OR 2 episodes within 12 hrs
I have examined and evaluated the patient for their reaction to the intervention, current medical and behavioral condition and
concur with the need FOR restraint or seclusion.
______________________________
DATE/TIME OF TELEPHONE ORDER
______________________________________________________
NAME OF DOCTOR / RN SIGNATURE
______________________________
______________________________________________________
DATE/TIME
PHYSICIAN SIGNATURE
WHITE - CHART YELLOW - NURSE MANAGER
FORM 322-0263 Rev. 4/09 (PART 1 OF 2)
RESTRAINT/SECLUSION/PHYSICIAN ORDER SHEET PATIENT CARE PLAN

FORM 322-0263 Rev. 4/09 (PART 2 OF 2)
VIOLENT OR SELF
DESTRUCTIVE BEHAVIOR
CLOSE WATCH
List of participants in this episode were:
________________________________________________________________
Restraint Order: Wrist Ankle Vest Pelvic Jacket Siderails (3 or more) Locked
Restraint Code: A = restraint applied B = restraint released Family notified Yes No Declines Unable to reach
Date Initiated _______________ Time initiated ____________ Initiated by: ____________________________________
Time / Code
Initials Time / Code
Initials Time / Code
Initials Nursing Assessment/Intervention Codes
0015
0815
1615
C= One hour RN face to face assessment
0030
0830
1630
D= Assessment by RN for physical and
0045
0845
1645
psychological status and comfort. Determine
readiness for discontinuation of restraints.
0100
0900
1700
E= Education provided to patient/family on
0115
0915
1715
rationale for restraint and release criteria
0130
0145
0200
0930
0945
1000
1730
1745
1800
F= Circulation check to restrained limbs
G= Continuous 1:1 (in person) monitoring with
15 minute assessment
0215
1015
1815
H= Restraints released for range of motion
every 2 hours for 15 minutes OR Position
0230
1030
1830
change/pressure point massage every 2 hours
0245
1045
1845
for 15 minutes
0300
1100
1900
I= Offered Fluid and Toileting every hour while
awake
0315
1115
1915
J= High risk medical conditions identified
0330
1130
1930
K= History of sexual abuse identified
0345
1145
1945
L= Refer to Interdisciplinary progress record for
0400
1200
2000
details
0415
0430
0445
0500
0515
0530
1215
1230
1245
1300
1315
1330
2015
2030
2045
2100
2115
2130
Patient Behavior Codes
1= Severely aggressive behavior which is a
danger to others
2= Severely aggressive behavior which is a
danger to self
3= Patient appears asleep at this time
4= Patient meets criteria for release at this time
0545
0600
0615
0630
0645
0700
0715
0730
0745
0800
1345
1400
1415
1430
1445
1500
1515
1530
1545
1600
2145
2200
2215
2230
2245
2300
2315
2330
2345
2400
Initials
Signature / Title
WHITE - PERMANENT MEDICAL RECORD

Patient Debriefing Process / documentation
Debriefing after seclusion/restraint is important in reducing the recurrent use of seclusion/restraint. The patient and
a family member with consent participate with the staff involved in the episode (Excluding staff which may
jeopardize the well-being of the patient). This should occur as soon as possible but no longer than 24 hours after
the episode.
Document below what was identified in the session:
What led to the incident ________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
What alternatives were tried that failed____________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Were the patient’s physical well being, psychological comfort and privacy addressed Yes _________ No ________
Explain:________________________________________________________________________________________________
What could have been handled differently ________________________________________________________________
______________________________________________________________________________________________________
If indicated counsel patient for any trauma than may have resulted from episode. Yes __________ No __________
__________________________________________________________________________________________________________________
If indicated how is the treatment plan being modified ______________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
List Participants: ________________________________________________________________________________________
______________________________________________________________________________________________________
Date and time of debriefing: _________________________________________ Document additional information in the
interdisciplinary notes.
__________________________________________________________________________________________________________________