RESTRICTIVE PRACTICE USE RECORD
Internal record for authorised regulated restrictive practices
1. Participant & Shift Details
Participant Name
First Name
Last Name
NDIS Number
Date of Support
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Worker Name(s)
Location / Activity
Current BSP date/version
2. Restrictive Practice Details
Type
Environmental
Chemical
Physical
Specific practice in BSP
Was it authorised and consistent with BSP?
Yes
No - notify supervisor immediately
Relevant BSP condition/protocol
3. Events Before Use
Behaviour/incident observed
Trigger/context (observable facts)
Strategies attempted first
Positive support
De-escalation
Redirection
Other
Back
Next
Outcome of strategies
4. Use of Restrictive Practice
Date used
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Start time
Hour Minutes
AM
PM
AM/PM Option
End time
Hour Minutes
AM
PM
AM/PM Option
Total duration
What was done?
How was it implemented?
Stopped as soon as safe?
Yes
No
5. Participant Outcome
Participant presentation afterwards
Injury or harm?
No
Yes
First aid/medical attention?
No
Yes
Did it achieve intended purpose?
Yes
No
Partially
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Next
6. Notifications & Follow-up
Supervisor/manager notified
No
Yes - date/time:
BSP practitioner notified
No
Yes - date/time:
Incident report completed
No
Yes - incident no.:
Further action required
No
Yes — details:
BSP review required?
No
Yes - refer to BSP practitioner
7. Worker Declaration
Worker declaration
I confirm this record is factual and the restrictive practice was implemented only as authorised and in accordance with the current BSP.
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Worker name/signature
8. Supervisor Review
Reviewed by
Review outcome
Compliant with BSP
Follow-up required
Escalated
Comments/actions
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature/date
NO RESTRICTIVE PRACTICE USED
For a shift where no regulated restrictive practice was used, record in the shift note: "No regulated restrictive practice was used during this shift."
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