APPENDIX

Appendix 1
Medical restraint flowsheet
I. Patient’s details
Name: Age: Gender: Male/female/others Hosp. No.
II. Clinician’s order
Name: Dr. Date: Time:
a. Doctor’s Orders (orders must be renewed every 12–24 h based on the practice)
1.
2.
3.
b. Initial Order
Start: Date/time
End: Date/time
c. Repeat order
Start: Date/time
End: Date/time
III. Alternatives attempted before initiation of medical restraints (check all that apply)
□Re-orient patient to time/date/place/person and/or situation
□Move patient closer to the nurses’ station
□Conceal lines/tubes/devices
□Minimize stimulation
□Reevaluate need for lines and tubes
□Appropriate diversional activities
□Repositioning
□Pain and sedation intervention
□Other
IV. Indication for using medical restraints
□Pulling lines
□Pulling tubes
□Removal of equipment
□Removal of dressing
□Inability to respond to direct requests or follow instructions
□Other
V. Type and details of medical restraints applied (Tick all that applies)
Wrists: Both/right only/left only
Legs: Both//right only/left only
Gloves/mittens: Both//right only/Left only
Waist Belt: Yes/No
Side railings: Yes/No
VI. Psycho-education of the patient
a. Informed the patient about the need and alternatives for medical restraints. Yes/No
b. Periodically patient has explained the behavior required to discontinue the restraint until an understanding was evidenced. Yes/No
Nurse’s name and sign Date and time
Doctor’s name and sign Date and time