Sepsis Management Note

Face to Face

Date&Time To be completed within 1-hour of restraint/seclusion application
Restraint Type	physical hold seclusion 2-point 4-point chemical *
Reason	behavior posing danger to self behavior posing danger to others combative, striking out at others agitation, escalating behavior, potential for violence threatening physical harm to others and to the environment threatening physical harm to self, out of control
Reaction	crying/tearful yelling/shouting pulling against restraints/struggling verbal threats calm/cooperative
Mental Status	alert/oriented paranoid pressure speech irritable agitated
Exam	vital signs stable skin warm/dry, no evidence of breakdown respirations regular and unlabored heart rate regular adequate intake, no nutritional compromise at this time denies pain
Review of History	Reviewed
Environment Safety Assessment	Safe
Criteria to discontinue	abstain from hitting or harming others abstain from verbal aggression towards others demonstrate insight or understanding of triggers demonstrate ability to manage anger resolve aggression ideation Contract for saftey upon release of restraints
Notification/education	patient family/significant other patient advocate
Recommendation	The patient MEETS criteria for continued restraints The patient meets criteria to DISCONTINUE restraints