Free Request for Use of Medical Restraints-F-62608 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62608 (Rev. 04/09)

STATE OF WISCONSIN Chapters 50.02(2) and 51.61(1)(i), Wis. Stats. DHS 94.10, Wis. Admin. Code

REQUEST FOR USE OF MEDICAL RESTRAINTS
Although completion of this form is voluntary, all the information requested on this form needs to be submitted as part of the approval process.
Name ­ Consumer Current Address ­ Consumer Birth Date City Type of Request

New
State Zip Code

Review

Name ­ Guardian Address ­ Guardian City

Telephone Number ­ Guardian State Zip Code

Current Residence ­ Consumer

Personal Residence (same address as above) Licensed or Certified Facility (Provide name and address below.) Other (Describe and provide address below.)

Street Address

City

State

Zip Code

Name - Facility Street Address - Facility

Facility Type Telephone Number

City

State

Zip Code

FAX Number

Is the consumer's proposed placement other than the current residence?
Name - Facility

Yes (Provide name below.)
Facility Type

No

Street Address - Facility

Telephone Number

City

State

Zip Code

FAX Number

Name ­ Agency Submitting This Request Name ­ Agency Contact Person Telephone Number FAX Number

Date Submitted E-mail Address

Street Address - Agency

City

State

Zip Code

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DEFINITIONS
A medical restraint is an apparatus or procedure that restricts the free, voluntary movement of a person and cannot be easily removed by the individual and a "Yes" to one of the following. Check "Yes" or "No" if the following apply. Yes No Medical Procedure Restraint Medical procedure or apparatus restraint used when necessary to accomplish diagnostic or therapeutic procedures ordered by a physician, physician's assistant or dentist.

Restraints Allowing Healing

Restraints for health-related conditions in order to allow healing of an injury. Examples of circumstances requiring healing may include lacerations, fractures, post-surgical wounds, skin ulcers and infections.

Long Term Restraints

Restraints used for protection from injury in the presence of a chronic health condition. An example is using a safety belt to protect an individual who has severe osteoporosis and ataxia.

If the answer to the Medical Restraint and any of the above definitions is "Yes," continue. PERSONAL SUMMARY
Type of Employment

Support Systems (name, address, telephone number, and relationship)

Interests

Dislikes

HEALTH CONSIDERATIONS
Diagnoses

Health Concerns

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MEDICATIONS
Medication Dose Purpose Prescribing Physician

HEALTH PROVIDERS
Specialty Primary Physician Psychiatrist Psychologist / Therapist Neurologist
Other Other Other

Name

Address

Telephone

MEDICAL CONDITION REQUIRING RESTRAINT
Describe the person's medical conditions and the situations in which they occur.

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Describe the frequency and duration of use.

Provide written authorization by a physician which identifies the type of medical restraint ordered, the indication for its use, and the time period for its application.

PREVIOUS ALTERNATIVE STRATEGIES OR INTERVENTIONS ATTEMPTED
List and explain previous alternative strategies or interventions, when they were tried, how long they were tried, and the outcomes 1. Strategy

Outcome

2.

Strategy

Outcome

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3.

Strategy

Outcome

4.

Strategy

Outcome

CURRENT AND PROPOSED STRATEGIES
Describe or attach a copy of the current and proposed strategies and safeguards for the medical condition. Include staffing patterns, level of supervision, restrictions, or limitations. Attach the current care plan, OT and PT evaluations, physician orders, and informed consent by the consumer or guardian.

RISK AND BENEFITS Describe a risk and benefit analysis for the use of the medical restraint.

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MEDICAL RESTRAINT Identify the proposed medical restraint and why these strategies are needed. Attach relevant photos, manufacturer specifications, or literature.
Plan Procedure / Device Purpose
(Specify where procedure or device is used, when, length of time, etc.)

Desired Outcome

REDUCTION AND ELIMINATION PLAN FOR RESTRAINTS
Describe or attach a copy of the plan for reducing and eventually eliminating the need for the medical restraint.

TRAINING
Describe or attach a copy of the plan to provide initial and on-going training for staff. Identify who will conduct the training, his/her credentials, the duration of training, and how training will be documented.

REVIEW
Describe or attach a description of how the plan will be monitored, documented, and reviewed.

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SUPPORT PLAN CONTRIBUTORS / DEVELOPERS
Name Relationship to Consumer

PLAN REVIEW
Plan Reviewed By Consumer (if not under guardianship * ) Guardian (if applicable * ) Placing Agency * Provider Agency * Primary Physician Other: Other: Other: Name Signature Date Reviewed

* Required signatures