Restraint Non-Violent/Non-Self Destructive Overview As per policy TX.10, use of the Non-Violent/Non-Self Destructive Restraint Orderset is primarily to protect the individual who is interfering with their medical devices and restraint alternatives attempted have not been effective. Restraints are not considered a part of the patient s standard treatment. Restraint Orderset Restraint Initiate Non- Violent/Non-Self Destructive Restraint Orderset The appropriate Restraint Orderset to be placed upon receiving the order for initiation of restraints is: 1. Click the Orders component from the menu. 2. Click the Add button. The Add Order window displays. 3. From the Orders window, double-click the Restraint Folder to open it. Initiate Orderset includes: Order will display on RN Tasklist. PowerForm is attached to the task for RN to document a comprehensive individual assessment, which led to restraint application. Restraint Non-Violent Evaluate Need to Continue Daily Order will display on RN Tasklist under the All Continuous Task tab. RN will need to ensure a new restraint order is entered on a daily basis. q2hr and Restraint Safety Checks Non-Violent/Non-Self Destructive q30min Order will display on RN Tasklist. RN will document their comprehensive individual assessment every 2 hours. EMR documentation should include patient condition as well as clinical need to maintain or discontinue the restraint. Restraint Safety Checks Non-Violent/Non-Self Destructive q30min has been included in the comprehensive individual assessment every 2 hours documentation. Restraint Non-Violent/Non-Self Destructive Careplan 4. Select appropriate orderset. 5. Click Done. Referral to Pharmacy This order will task Pharmacy to see the patient for Medication Review post restraint initiation.
Restraint Non-Violent/Non-Self Destructive (Page 2) Restraint Orderset (continued) 6. When staff is entering restraint orders for orders on provider s behalf: Ordering Physician box displays. Enter ordering provider s name and appropriate communication type for how order was given. Pop-up for direction regarding ordering Restraint Type(s) in the Restraint Initiate or Restraint Continue Non-Violent/Non- Self Destructive order. Restraint Orderset (continued) 9. Click Sign, then Refresh the screen. 10. Restraint Initiate Non-Violent/Non-Self Destructive and Restraint Non-Violent/Non-Self Destructive Careplan displays in the view pane under Medical. After the orderset is signed, the Nurse Review icon displays next to orders in the order profile section and on the PAL (if entered by provider or another nurse). FOR ED ONLY: The R icon will display under the Orders section of the FirstNet Tracking board for each Restraint Orderset that was placed by the provider. 7. Restraint Face To Face Assessment: a. PowerForm will display. b. Staff will enter Yes for the field, Are you a nonprovider?, then click the green checkmark in the corner to sign the PowerForm and the form will close. 11. As per policy, call provider to examine the patient. 12. Document Provider Notification under the Events and Procedures band in Interactive View. The patient is required to have an in-person assessment within 2 hours of restraint application. RN-Restraint Initiate Non-Violent/Non-Self Destructive Task 1. Click on the Tasklist component of the menu. 8. In the Restraint Initiate Non-Violent/Non-Self Destructive: a. Select appropriate reason(s) for Reason for Restraint Non- Violent/Non-Self Destructive. Interfering with Medical Devices defaults 2. Double-click on the Restraint Initiate Non-Violent/Non-Self Destructive Task. The Restraint Initiate Non-Violent/Non-Self Destructive PowerForm displays. 3. If needed, modify the date and time of when assessment was done in the Performed on field on the PowerForm. It is located in the upper left corner of the form. 4. Episode start is the first section of the PowerForm; you must complete the Restraint Initiation Date/Time field. It is a required field. NOTE: b. Select Restraint Type. If more than 1 restraint type needs to be ordered, hold CTRL key on keyboard while left-clicking the Restraint Type selections. Reminder for Non-Violent/Non-Self Destructive orders: Ankle and Wrist should not be ordered together.
Restraint Non-Violent/Non-Self Destructive (Page 3) RN-Restraint Initiate Violent/Self Destructive Task (continued) 5. Click on the Initiation section of the form. 6. Document in the following areas with the appropriate clinical ***All fields are required*** Restraint Type Location of Restraint Application Reason/Behavior Necessitating Restraints Behavior Description Restraint Alternatives Attempted Notification of Restraint If yes is selected, individual notified of restraint If no is selected, reason for non-notification 7. Click on the Education section of the form. 8. Document the following areas with the appropriate Home Caregiver Present for Session Barriers to Learning Teaching Method Policy Regarding Use of Restraints Reason for Use of Restraints Restraint Release Criteria NOTE: For Document Learning Evaluation for Responsible Learner(s) section: Clicking on a column header within a grid selects all cells within the column. RN-Restraint Safety Check Violent/Self Destructive q2hr Task 1. Click on the Tasklist component of the menu. 2. Double-click on the Restraint Assess/Reassess Non-Violent/ Non-Self Destructive q2hr Task. 3. If needed, modify the date and time of when the assessment was done in the *Performed on field in the PowerForm. It is located in the upper left corner of the form. If yes, click Yes and fill out the sections of the form, which are all required. Required sections include: Restraint Type Location of Restraint Application Restraint Safety Checks Restraint Activity Circulation/Skin Range of Motion/Positioning LOC (Level of Consciousness) Nutrition/Hydration Hygiene/Elimination Respirations Respiratory Pattern Patient Safety Affect/Behavior While in Restraints Restraints Alternative Attempted Evaluation of Status While in Restraints. 9. Click Sign. Checkmark icon displays on the upper left corner of the form. Task will display as complete. RN-Restraint Safety Check Violent/Self Destructive q30min Task The RN - Restraint Assess/Reassess Non-Violent/Non-Self Destructive q2hr PowerForm includes a field to document the Restraint Safety Checks. RN should select Q30min Non-Violent Safety Check Protocol for Non-Violent/Non-Self Destructive Restraints. This is the confirmation that the Restraint is applied and secured in accordance to the manufacturer s instructions and ensures that the device will not tighten or loosen as the bed is raised or lowered. The patient has been examined for the presence of any marks on their skin at the restraint site as well as circulation at the restraint site. Offer opportunities for patient care/needs to be met.
Restraint Non-Violent/Non-Self Destructive (Page 4) RN-Restraint Safety Check Violent/Self Destructive q2hr Task (continued) 4. Complete the Education section of the form. Document the following areas with the appropriate Home Caregiver present for session Barriers to Learning Teaching Method Policy Regarding Use of Restraints Reason for Use of Restraints Restraint Release Criteria Restraint Continue Non-Violent/Non-Self Destructive Workflow The order, Restraint Non-Violent Evaluate Need to Continue, will task the RN under the All Continuous Tasks as a daily reminder for the RN to verify that the Restraint Continue Non-Violent/Non-Self Destructive orderset was placed by the provider. 1. If the patient still requires Non-Violent/Non-Self Destructive restraints, the RN will need to notify the Provider of need for new order on a daily basis. 2. Provider (or RN on behalf of Provider) will need to enter Restraint Continue Non-Violent/Non-Self Destructive Orderset. 3. RN will complete Restraint Continue Non-Violent/Non-Self Destructive PowerForm from Tasklist. 4. Follow steps as outlined in the RN - Restraint Safety Check Non- Violent/Non-Self Destructive q30min task and RN - Restraint Assess/Reassess Non-Violent/Non-Self Destructive q2hr task. NOTE: Clicking on column header within a grid selects all cells within the column. Restraint Careplan Review 1. Click the Task List component from the menu. Note the Review Care Plan Task. 2. Click the Orders component from the menu. 3. Click the Document in Plan tab. 4. Click Document button to chart Goals - Met or Not Met. 5. Click Document button to chart Interventions - Done or Not Done. 6. Click Sign Documentation button. 7. Click the Task List component from the menu. 8. If applicable, Chart Done for Review Care Plan Task. 9. Click Refresh. Review Care Plan task falls off Task List. 5. Click Sign. Checkmark Icon displays on the upper left corner of the form. Task will display as complete.
Restraint Non-Violent/Non-Self Destructive (Page 5) Restraint Discontinue 1. Click AdHoc icon from the toolbar. 2. Click on Restraint folder and select Restraint Discontinue PowerForm. 3. Document all required fields. Restraint Discontinue Date/Time Criteria Met for Restraint Discontinue Restraint Type (which were removed from the patient) Patient has been removed from restraints; discontinue the Restraint Non-Violent/Non-Self Destructive Orderset/Careplan. 1. Click the Orders component from the menu. 2. In the View Pane under Plan, click the Medical Folder to display initiated ordersets. 3. Right-click on the Restraint Non-Violent/Non-Self Destructive Orderset. 4. Select Discontinue from the shortcut menu. 5. Click on the Discontinue Reason drop-down. 6. Select the Appropriate Reason. 7. Click the OK button. The Ordering Physician dialogue displays. 8. Enter the Ordering Physician s name. 9. Enter Communication Type: Protocol - No Co-Signature Required. 10. Click the OK button. 11. Click the Orders for Signature button. 12. Click the Sign button. Restraint Orderset Discontinuation The Restraint tasks fall off the Tasklist (if the tasks were scheduled at the time or after orderset discontinuation). Non Task List Areas 1. Provider enters Restraint Initiate Non-Violent/Non-Self Destructive Orderset. 2. After Nurse Review of order, RN documents in PowerForms from AdHoc tab in the toolbar. PowerForm q2hr PowerForm Restraint Renewal Order 1. Provider enters Restraint Continue Non-Violent/Non-Self Destructive Orderset. 2. After Nurse Review of order, RN documents in Powerform from AdHoc tab in the toolbar. Restraint Continue Non-Violent/Non-Self Destructive PowerForm Age Specific q2hr PowerForm