National Association of Psychiatric Health Systems (NAPHS)

Sample Forms and Checklists (PDF)

Includes:

• Patient Debriefing Tool Following Restraint/Seclusion-provided by Stone
  Institute of Psychiatry, Northwestern Memorial Hospital, Chicago, IL

• Core Skills and Knowledge for Direct Care Staff -provided by Ardent Health
  Services—Behavioral Health Group, Nashville, TN

• Competency Test: Care of the Patient in Restraints or Seclusion-provided by
  Stone Institute of Psychiatry, Department of Psychiatric Nursing, Northwestern Memorial
  Hospital, Chicago, IL

• Patient Reported Therapeutic Interventions Survey-provided by the Milwaukee
  County Mental Health Division, Milwaukee, WI  (MCBHD)

• De-Escalation Tips-provided by the Milwaukee County Mental Health Division,
  Milwaukee, WI  (MCBHD)

• Checklist for Using Seclusion and Restraintfrom Melonas, J. (2000, December 1).
  Seclusion and restraint. Dos and don’ts. Psychiatric News, pp. 9, 47.

• Restraint/Seclusion Assessment and Physician Order Set(MC 1156-41 and
  MC 1156-42)-used at Mayo Medical Center and copyrighted by ©Mayo Foundation for
  Medical Education and Research (MFMER)