The DHS F-62608 form, emanating from the Department of Health Services within the State of Wisconsin, serves as a quintessential document within the division of Quality Assurance, adhering to the statutes outlined in Chapters 50.02(2) and 51.61(1)(i), Wis. Stats., and aligned with DHS 94.10 of the Wisconsin Administrative Code. This form is integral for those seeking authorization for the use of medical restraints, a term that encompasses both apparatus and procedures designed to limit the voluntary movement of an individual in a manner that is not easily overridden by the person in question. The form requests comprehensive information from basic identification details of the consumer, including the name, birth date, and current residence, extending to the guardian's information, if applicable. Additionally, it covers the existing and proposed living arrangements of the consumer, information about the facility (if any) where the consumer resides or will reside, and details about the agency initiating the request. Further, this form delves into the medical justification for the restraint, asking for a description of the medical condition necessitating its use, the frequency and duration of the proposed restraint use, past strategies or interventions attempted before resorting to restraints, and detailed plans for the implementation of current and proposed strategies for managing the individual’s medical condition. Essential to this process is a balanced analysis of the risks and benefits associated with the use of medical restraints, aiming to safeguard the individual’s health and well-being while respecting their autonomy and freedom to the greatest extent possible.
| Question | Answer |
|---|---|
| Form Name | Dhs Form F 62608 |
| Form Length | 7 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 45 sec |
| Other names | F62608 wisconsin dhs request for use of medical restraints f 62608 form |
DEPARTMENT OF HEALTH SERVICES |
STATE OF WISCONSIN |
Division of Quality Assurance |
Chapters 50.02(2) and 51.61(1)(i), Wis. Stats. |
DHS 94.10, Wis. Admin. Code |
REQUEST FOR USE OF MEDICAL RESTRAINTS
Although completion of this form is voluntary, all the information requested on this form needs to be submitted as part of the approval process.
Name – Consumer |
Birth Date |
Type of Request |
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New |
Review |
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Current Address – Consumer |
City |
State |
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Zip Code |
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Name – Guardian
Address – Guardian
Telephone Number – Guardian
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State |
Zip Code |
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Current Residence – Consumer
Personal Residence (same address as above)
Licensed or Certified Facility (Provide name and address below.)
Other (Describe and provide address below.)
Street Address |
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Zip Code |
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Name - Facility |
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Facility Type |
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Street Address - Facility |
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Telephone Number |
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Zip Code |
FAX Number |
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Is the consumer’s proposed placement other than the current residence?
Yes (Provide name below.)
No
Name - Facility |
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Facility Type |
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Street Address - Facility |
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Telephone Number |
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FAX Number |
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Name – Agency Submitting This Request |
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Date Submitted |
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Name – Agency Contact Person |
Telephone Number |
FAX Number |
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Street Address - Agency |
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Page 2 |
DEFINITIONS
A medical restraint is an apparatus or procedure that restricts the free, voluntary movement of a person and cannot be easily removed by the individual and a “Yes” to one of the following. Check “Yes” or “No” if the following apply.
Yes No
Medical |
Medical procedure or apparatus restraint used when necessary to accomplish diagnostic or therapeutic |
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Procedure |
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procedures ordered by a physician, physician’s assistant or dentist. |
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Restraint |
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Restraints |
Restraints for |
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circumstances requiring healing may include lacerations, fractures, |
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Allowing Healing |
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and infections. |
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Long Term |
Restraints used for protection from injury in the presence of a chronic health condition. An example is |
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Restraints |
using a safety belt to protect an individual who has severe osteoporosis and ataxia. |
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If the answer to the Medical Restraint and any of the above definitions is “Yes,” continue.
PERSONAL SUMMARY
Type of Employment
Support Systems (name, address, telephone number, and relationship)
Interests
Dislikes
HEALTH CONSIDERATIONS
Diagnoses
Health Concerns
Page 3 |
MEDICATIONS
Medication
Dose
Purpose
Prescribing Physician
HEALTH PROVIDERS
Specialty
Name
Address
Telephone
Primary Physician
Psychiatrist
Psychologist / Therapist
Neurologist
Other
Other
Other
MEDICAL CONDITION REQUIRING RESTRAINT
Describe the person’s medical conditions and the situations in which they occur.
Page 4 |
Describe the frequency and duration of use.
Provide written authorization by a physician which identifies the type of medical restraint ordered, the indication for its use, and the time period for its application.
PREVIOUS ALTERNATIVE STRATEGIES OR INTERVENTIONS ATTEMPTED
List and explain previous alternative strategies or interventions, when they were tried, how long they were tried, and the outcomes
1.Strategy
Outcome
2.Strategy
Outcome
Page 5 |
3.Strategy
Outcome
4.Strategy
Outcome
CURRENT AND PROPOSED STRATEGIES
Describe or attach a copy of the current and proposed strategies and safeguards for the medical condition. Include staffing patterns, level of supervision, restrictions, or limitations. Attach the current care plan, OT and PT evaluations, physician orders, and informed consent by the consumer or guardian.
RISK AND BENEFITS
Describe a risk and benefit analysis for the use of the medical restraint.
Page 6 |
MEDICAL RESTRAINT
Identify the proposed medical restraint and why these strategies are needed.
Attach relevant photos, manufacturer specifications, or literature.
Procedure / Device
Purpose
Plan
(Specify where procedure or device is used,
when, length of time, etc.)
Desired Outcome
REDUCTION AND ELIMINATION PLAN FOR RESTRAINTS
Describe or attach a copy of the plan for reducing and eventually eliminating the need for the medical restraint.
TRAINING
Describe or attach a copy of the plan to provide initial and
REVIEW
Describe or attach a description of how the plan will be monitored, documented, and reviewed.
Page 7 |
SUPPORT PLAN CONTRIBUTORS / DEVELOPERS
Name
Relationship to Consumer
PLAN REVIEW
Plan Reviewed By |
Name |
Signature |
Date Reviewed |
Consumer (if not under guardianship * )
Guardian (if applicable * )
Placing Agency *
Provider Agency *
Primary Physician
Other:
Other:
Other:
* Required signatures