Raven EMS Education Program Manual Behavioral Restraints Evaluation Form
Date:
Student name:
Evaluator name:
Steps:
Take BSI and scene safety precautions.
Request additional resources as needed.
Explain the procedure to the patient or family as best as possible.
Prepare gurney restraints and seat belts.
Assist the patient onto the gurney.
Assess CMS in all four extremities if possible.
Secure the ankles with restraints (must be able to slide at least one finger between the restraints and the patient’s limb so as not to cut off circulation).
Secure the wrists with restraints (must be able to slide at least one finger between the restraints and the patient’s limb so as not to cut off circulation).
Secure the patient to the gurney with seat belts.
Sit patient upright in sitting position.
Reassess CMS in all four extremities.
Continue to monitor, reassure, and reassess the patient.
Accepts evaluation and criticism professionally.
Shows willingness to learn/asks appropriate questions.
Interacts with simulated patient and other personnel in a professional manner (ie, uses appropriate name, explains procedures, maintains modesty, is courteous to crew, etc).
Passing criteria:
Pass: At least 70% (11 of 15) successfully completed above. Currently at 0% completed.
Fail.
Fails to take BSI precautions prior to performing procedure.
Fails to consider scene safety.
Did not explain and reassure the patient.
Fails to check CMS after applying restraints.
Loses temper or shows disrespect or anger towards patient.
