| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | file entry date(+) | 0;1 | DATE-TIME | B | Actual date/time of entry of transaction into file. This field is transparent to the user. | |
| .02 | name(+) | 0;2 | POINTER | 2 | C | Name (DFN) of patient placed under seclusion and/or restraint for this episode. |
| .03 | date/time applied(+) | 0;3 | DATE-TIME | Date/time seclusion and/or restraint actually applied to patient. | ||
| .04 | ward(+) | 0;4 | POINTER | 44 | Ward (hospital location) seclusion/restraint occurred. | |
| .05 | name of nurse present(+) | 0;5 | POINTER | 200 | Supervisory nurse responsible for carrying out of seclusion/restraint action. | |
| .06 | nursing shift(+) | 0;6 | POINTER | 211.6 | Nursing shift during which seclusion/restraint episode commenced. | |
| .08 | patient searched | 0;8 | BOOLEAN | Y:YES N:NO | Question as to whether or not a patient was searched for possible harmful objects on his/her person. | |
| .09 | search comment | 2;0 | WORD-PROCESSING | If a patient was not searched, a reason must be given as to why the procedure was not done. | ||
| 4 | initial transcriber(+) | 1;4 | POINTER | 200 | Person placing information into file. TRANSPARENT TO USER. | |
| 5 | type of seclusion/restraint | 5;0 | MULTIPLE | 615.34 | Manner in which seclusion/restraint is performed. | |
| 6 | attempted alternatives | 6;0 | MULTIPLE | 615.35 | Different clinical strategies employed prior to placing patient into seclusion/restraint. | |
| 7 | diagnosis(+) | 7;1 | FREE TEXT | The diagnosis may be an actual DSM diagnosis selected from the PTF file or it may be a perceived diagnosis by caretaker. | ||
| 10 | reasons for s/r | 10;0 | MULTIPLE | 615.21 | A reason for the seclusion/restraint action. | |
| 15 | medications | 15;0 | MULTIPLE | 615.23 | A list of medications given to the patient during this seclusion/restraint episode. | |
| 20 | behavior required for release | 20;0 | MULTIPLE | 615.24 | Actions required on the part of the patient prior to release from seclusion/restraint. | |
| 25 | ordered by(+) | 25;1 | POINTER | 200 | Caretaker responsible for initiating the seclusion/restraint action. | |
| 26 | order type(+) | 25;2 | SET OF CODES | w:WRITTEN e:EMERGENCY p:PHONE | Method by which the seclusion/restraint order was conveyed by the responsible caretaker to appropriate personnel. | |
| 27 | date/time of order(+) | 25;3 | DATE-TIME | Date and time the order was written, phoned or the situation required emergency action. | ||
| 28 | date order changed(+) | 25;4 | DATE-TIME | Field will only contain data when the order is altered. It indicates the date and time the order was changed. TRANSPARENT TO USER. | ||
| 30 | general comments | 30;0 | WORD-PROCESSING | Additional comments concerning this seclusion/restraint episode. | ||
| 40 | release ordered by(+) | 40;1 | POINTER | 200 | Caretaker ordering cessation of seclusion/restraint order. | |
| 41 | personnel effecting release(+) | 40;2 | POINTER | 200 | Personnel actually performing release of patient from seclusion/restraint. | |
| 42 | time removed(+) | 40;3 | DATE-TIME | Actual date/time release was performed. | ||
| 43 | release transcriber(+) | 40;4 | POINTER | 200 | Person entering release information into file. TRANSPARENT TO USER. | |
| 44 | release filed(+) | 40;5 | DATE-TIME | Date/time release information placed in file. TRANSPARENT TO USER. | ||
| 45 | circumstances/further actions | 45;0 | WORD-PROCESSING | Narrative concerning release action and possible follow-up care. | ||
| 50 | reviewed by(+) | 50;1 | POINTER | 200 | Personnel, in authority, reviewing action. | |
| 51 | action(+) | 50;2 | SET OF CODES | A:APPROPRIATE I:INAPPROPRIATE O:OTHER (See Reviewer's Comments) | Decision of the reviewer as to whether or not action taken was appropriate. | |
| 52 | actual date of review(+) | 50;3 | DATE-TIME | Actual date/time review was made by personnel. | ||
| 53 | review transcriber(+) | 50;4 | POINTER | 200 | Personnel entering review into file. TRANSPARENT TO USER. | |
| 54 | review filed(+) | 50;5 | DATE-TIME | Actual date/time review entered into file by transcriber. | ||
| 55 | reviewer's comments | 55;0 | WORD-PROCESSING | Narrative of additional comments provided by the reviewer. | ||
| 60 | observation check time | 60;0 | MULTIPLE | 615.3 | A history of observations performed during a single patient episode. |
Not Referenced