Received patient during handoff. Patient noted to be in non-behavioral soft restraints to bilateral upper extremities (right and left wrists). Indication: risk of harm to self related to pulling at lines/tubes. Active restraint order verified in EMR and current. Skin to restrained extremities intact with no redness, breakdown, or swelling noted at this time.

Patient has [list lines/drains/tubes] in place:

IV access: [e.g., PIV to left forearm, patent, saline locked / infusing per MAR] Tubes: [e.g., Foley catheter draining clear yellow urine / NG tube infusing tube feeds at ___ mL/hr] Drains: [if applicable]

Restraints positioned appropriately, circulation/motion/sensation intact to all extremities. Bed in low position, call light within reach, safety precautions in place.