Triggers:

Check if  applicable

P0100A-H

Bed rail, Chair prevents rising,

Trunk, Limb or other restraint in bed, chair, or out of bed

Evaluate:

B0600-B0800

Impaired communication

C0200-C1000

Cognitive loss/dementia

C1300

Delirium

D

Sad/anxious mood

E

Any behavioral symptoms

E0800

Rejection of care

G0110

ADL performance impaired or decline

H0100

Indwelling or External Catheter, Ostomy

I

Neurological or Psychiatric diagnosis

I3900

Hip fracture

J1700-J1900

Falls

K0500A, B

Parenteral / IV / Feeding tube

M0210

Pressure Ulcer

M1200

Wound care/treatment

N0400A-D

Psychotropic use

O0100C

Oxygen

O0100F

Respirator or Ventilator

O0100H, I

IV Meds, Transfusions

Reason for restraint

Less restrictive device attempted

Regular schedule for removing, checking on safety, needs, comfort

Plan for reducing / eliminating

Proceed with care-planning

Do not proceed with care-planning

Underlying Causes / Complicating factors / Risks / Referrals

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