Who authorized/approved restraint (longer than 30 minutes) __________________________________ Was there injury to the client? Yes or No Did the client require treatment? Yes or No Was there injury to staff? Yes or No Did staff require treatment? Yes or No Rights Limitations/Restrictions Summary of How were the youth’s rights limited or restricted? Response: Describe provider response to situation? Debriefing with youth? Guardian notified/involved? Type of Rights Limitations/Restrictions (Check all that apply) Religious Practice □ Behavior modifications □ Medical Care Social Activity □ □ Communication □ Nutrition Voting (18-21 yo) □ □ Confidentiality (HIPPA) □ Physical Restraint Work □ □ Discipline □ Personal property Record □ □ Humane Treatment □ Physical Exercise Seclusion □ □ Serious Injury to Client Summary of Event: Describe any harm that required emergency services (key words are services”). “emergency Describe type of injury and what caused injury. Only report events that occur during the provision of services. Response: Describe provider response to situation. What treatment was received and Type of injury: Cause of Injury: Lacerations requiring stitched/staples Fall Origin unknown □ □ □ Bone fracture/break Accident Quality of care □ □ □ Joint dislocation Seizure Near drowning □ □ □ Head injury Medical Other: ________________ □ □ Serious burn Condition □ Skin wound Treatment error □ □ Other _____________________ Where did person receive treatment: ER Intervention on site Urgent Care □ □ □ Admitted to hospital Primary Care Other: __________________ □ □ Suicide
Who authorized/approved restraint (longer than 30 minutes) __________________________________ Was there injury to the client? Yes or No Did the client require treatment? Yes or No Was there injury to staff? Yes or No Did staff require treatment? Yes or No Rights Limitations/Restrictions Summary of How were the youth’s rights limited or restricted? Response: Describe provider response to situation? Debriefing with youth? Guardian notified/involved? Type of Rights Limitations/Restrictions (Check all that apply) □ Behavior modifications □ Communication □ Confidentiality (HIPPA) □ Discipline □ Humane Treatment □ Medical Care □ Nutrition □ Physical Restraint □ Personal property □ Physical Exercise □ Religious Practice □ Social Activity □ Voting (18-21 yo) □ Work □ Record □ Seclusion Serious Injury to Client Summary of Event: Describe any harm that required emergency services (key words are “emergency services”). Describe type of injury and what caused injury. Only report events that occur during the provision of services. Response: Describe provider response to situation. What treatment was received and Type of injury: □ Lacerations requiring stitched/staples □ Bone fracture/break □ Joint dislocation □ Head injury □ Serious burn □ Skin wound Other _____________________ Cause of Injury: □ Fall □ Accident □ Seizure □ Medical Condition □ Treatment error □ Origin unknown □ Quality of care □ Near drowning Other: ________________ Where did person receive treatment: □ ER □ Admitted to hospital □ Intervention on site □ Primary Care □ Urgent Care Other: __________________ Suicide
OCFS%20Reportable%20Events%20Form%209-18.docx