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Use of Restraint Check List

Date: __________________                                                        CAD #__________________

Patient Name: _____________________________            _______________________________

                                    (Last name)                                               (First name)

I.                    Reason for restraint application (check all that apply):

1.       _____  Patient is a harm to self

2.       _____  Patient is a harm to others

3.       _____  Patient uncooperative with required medical treatment

II.                  _____  Medic attempted verbal reassurance and/or redirection.

III.                _____  Medic attempted a change of environment for the patient

IV.                _____  Type of restraint applied (check all that apply):

1.       _____  Limb restraint

a.       _____  LUE

b.       _____  RUE

c.       _____  LLE

d.       _____  RLE

2.       _____  Chemical restraint

a.       agent administered: ____________________________

b.       dose of agent: ________________________________

c.       time administered: _____________________________

d.       Patient tolerance: _____________________________

V.                  _____  Vitals signs and assessment of neurovascular status performed every 10 minutes

VI.                Position of Patient (Not Prone)

1.       _____  Supine position for transport

2.       _____  Lateral recumbent position for transport