Pa. Code tit. 55, pt. VIII, subpt. A, ch. 6000, subch. R, STATUTES, app I

Current through Register Vol. 54, No. 45, November 9, 2024

Appendix I - ABBREVIATED INCIDENT REPORT

Restraint

The data entry screen is to include the following information:

* DEMOGRAPHICS (prepopulated from HCSIS demographics)

Name of the individual for whom the Restraint was used.

Individual's Base Service Unit (BSU) number.¹

¹ If the individual is not registered with a County MH/MR Program, the report is to list the county or state where the person is/was a resident.

* CATEGORIZATION

Secondary category of Restraint.

Date of the Restraint.

Time in Restraint.

Time out of Restraint.

* RESTRAINT INCIDENT INFORMATION

Restraint agent.

Antecedent to the Restraint.

Reason for the Restraint.

Indication if the Restraint was used on a planned or emergency basis.

Authorizing Staff.

Indication if Prone (face down) Restraint was used.

Indication if another Incident Report was filed as a result of the Restraint.

If another Incident Report was filed the Incident ID number.

Pa. Code tit. 55, pt. VIII, subpt. A, ch. 6000, subch. R, STATUTES, app I

The provisions of this Appendix I adopted February 27, 2004, effective 2/21/2004, 34 Pa.B. 1234.

This appendix cited in 55 Pa. Code § 6000.923 (relating to incidents to be reported within 72 hours).