Restraint Orders

1. Type of Restraint: Seclusion, 4-point leather restraint, or soft restraints.

2. Indication: Confused, threat to self Agitated, threat to self Combative, threat to self/others Attempting to pull out tube, line, or dressing Attempting to get our of bed, fall risk

3. Time

Begin at_o'clock.

Not to exceed (specify number of hours)

4. Monitor patient as directed by hospital policy

5. Staff may decrease or release restraints at their discretion

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