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Physical Restraint Monitoring Form

This document is a physical restraint order form from Bajwa Hospital. It orders the physical restraint of a patient, citing the reason as self-harm or harm to others. The type of restraint is for both wrists and the type of device is padded bandages. The order is valid for up to 12 hours and requires ongoing assessment of the patient's condition, including skin integrity, vital signs, toileting, and feeding, to be recorded every two hours.

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Chandu Pandit
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3K views

Physical Restraint Monitoring Form

This document is a physical restraint order form from Bajwa Hospital. It orders the physical restraint of a patient, citing the reason as self-harm or harm to others. The type of restraint is for both wrists and the type of device is padded bandages. The order is valid for up to 12 hours and requires ongoing assessment of the patient's condition, including skin integrity, vital signs, toileting, and feeding, to be recorded every two hours.

Uploaded by

Chandu Pandit
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Pt.

Name: __________________________
Age: _____________ Sex: ____________
UHID:____________ IPID:__________
BAJWA HOSPITAL Consultant:________________________
PHYSICAL RESTRAINT ORDER DOA: ____________ Deptt. ___________

(VALID UPTO 12 HR. ONLY)


Reason For Restraint: Self harm Harm to others Potential for removing lines Others

Type of Restraint: Physical=P (Left Wrist=LW: Right Wrist=RW: Left Ankle=LA Right Ankle=RA)

Chest=Ch: Chemical Restraints (Drugs)=D)


Type of device: Padded Bandage=PB: Padded Bed Sheet=PBS: Others
Restraint education provided to: Patient Yes No Family Yes No
Present status and reasons for restrain have been expalained.

Signature of the relative/attendant: ________________________ Name: _____________________________ Relation: ______________

Date: _______________________ Time: ______________________________


Ordered By Dr. on Time (from): Time (valid upto): Signature:
Rpt. Order By Dr.: on Time (from): Time (valid upto): Signature:
ON GOING ASSESSMENT: Type of Restraint ______________________ Type of device_____________________ Date________________
08 AM 10 AM 12 PM 02 PM 04 PM 06 PM 08 PM 10 PM 12 AM 02 AM 04 AM 06 AM
Skin Intact

Skin cleaned & massaged

Pulse Checked

RR & breath sounds (WNL)

Patient voidedYes/No

Patient fed. Yes/No

Signature of S/N

Present status and reasons for restrain have been expalained.

Signature of the relative/attendant: ________________________ Name: _____________________________ Relation: ______________

Date: _______________________ Time: ______________________________


Ordered By Dr.: _____________________________ on: ________ Time (from): _________ Time (Valid upto): ________ Signature:________

Rpt. Order By Dr.:___________________________ on: ________ Time (from): _________ Time (Valid upto): ________ Signature:________

ON GOING ASSESSMENT: Type of Restraint ___________________ Type of device _____________________ Date _____________________
08 AM 10 AM 12 PM 02 PM 04 PM 06 PM 08 PM 10 PM 12 AM 02 AM 04 AM 06 AM
Skin Intact

Skin cleaned & massaged

Case Checked

RR & breath sounds (WNL)

Patient voided Yes/No

Patient fed. Yes/No

Signature of S/N

Form ________

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