SaltLakeCounty Jail Intensive Management Flowsheet

Prisoner Name:______SO#:______Date:______

1.Physician initiating Intensive Management:______

2.Prisoner placed in: Seclusion FSP Status 2 pt Restraint 4 pt Restraint 5 pt Restraint Forced medication

3.Time-Intensive Management initiated:______ Order documented in Medical Record

4.Time physician evaluated prisoner:______(Policy requires that evaluation occur within four hours).

5.Health Services Unit Administrator______notified at:______.

6.Rationale for Intensive Management:

Substantial likelihood of immediate physical harm to the prisoner as demonstrated by credibly threatened or actual self-destructive behavior.

Behavior of the prisoner creates a continuation of a health hazard or potential health hazard to staff or other prisoners.

Significant threat to county property exists and other measures have failed.

Restraint or Seclusion offers less risk of injury to the prisoner, staff, or others than other readily available options.

Specific behavior:______

7.Alternatives attempted:

 Prisoner removed from stimuli Verbal calming Crisis evaluation Voluntary medication offered:______

Other: ______

8.Contraindications: Do conditions exist which may be exacerbated by physical restraint exist (bone or joint trauma, vascular disease, etc)?

 No Yes, explain:______

9.Method used to place prisoner in restraints:

 Prisoner went voluntarily Prisoner refused direct order Custody intervention required to place prisoner in restraints

10.Physical assessment of prisoner immediately after initiation of Intensive Management:

 No apparent injury Injury present—documented in medical record

11.Physician-ordered criteria for the discontinuation of Intensive Management:

 Prisoner demonstrates self-control Risk of harm to self or others no longer present Able to understand/contract for safety

Other:______

Signature of RN initiating Intensive Management:______Date:______

12.Prisoner response to Intensive Management:
______

13.Continuation of orders. Initial order to expire at:______(Initial order time limited to 4 hours)

14.Criteria for discontinuation not met and orders documented in medical record every 4 hours as summarized below:

4 hour:______(ordering provider)______(time)

8 hour:______(ordering provider)______(time)

12 hour:______(ordering provider)______(time)

16 hour:______(ordering provider)______(time)

20 hour:______(ordering provider)______(time)

15.Criteria for release met:

Intensive Management discontinued at:______

Physical Assessment of prisoner immediately afterwards: No apparent injury Injury present—documented in medical record

Signature of RN discontinuing Intensive Management:______Date:______