FORM 10E

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FORM 10E – RECORD OF EXAMINATION OF RESTRAINED

FORM 10E – RECORD OF EXAMINATION OF RESTRAINED PERSON AND. POSSIBLE EXTENSION OF BODILY RESTRAINT. Date and time of examination: Date: DD/MM/YY Time: HH:MM.

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FORM 10E – RECORD OF EXAMINATION OF RESTRAINED

March 2016

CHIEF PSYCHIATRIST

WESTERN AUSTRALIA

WA MENTAL HEALTH

ACT 2014

Please use ID label or block print

FAMILY NAME

UMRN

GIVEN NAMES

CMHI

BIRTHDATE

GENDER

ADDRESS

SECTIONS: 234, 238

FORM 10E - RECORD OF EXAMINATION OF RESTRAINED PERSON AND

POSSIBLE EXTENSION OF BODILY RESTRAINT

Date and time of examination: Date: DD/MM/YY Time: HH:MM

(Must be within 30 minutes from the time the person was restrained, or last examination)

Results of examination:

Having regard to the criteria for authorising bodily restraint (see overleaf) should the bodily restraint order: Be revoked - see Form 10G - Revocation or expiry of bodily restraint order Be varied - see Form 10F - Variation of bodily restraint order

Continue until it expires.

Be extended.

If so, period of order extended for: ______________________________________________ (up to a further 30 mins from end of restraint period) Date and time extension order made: Date: DD/MM/YY

Time: HH:MM

Date and time bodily restraint to end because of extension: Date: DD/MM/YY

Time: HH:MM

Reasons for extending order:

Name of medical practitioner: ___________________________________________________ Qualifications of medical practitioner: _____________________________________________ Signature of medical practitioner: _________________________________________________

If person has been restrained for a total

period of longer than 6 hours , restraint must be reviewed by a psychiatrist. See Form 10H - Review of bodily restraint by a psychiatrist.

If additional space is needed (ie

- if there is more than one examination by a medical practitioner) complete another Form 10E.

RECORD OF EXAMINATION OF RESTRAINED PERSON AND

EXTENSION OF BODILY RESTRAINT

March 2016

Notes: Form 10E - Record of examination of restrained person and extension of bodily restraint

When to use this form:

A medical practitioner must examine the restrained person at least every 30 minutes and record the results of the examination using this form, including whether or not the medical practitioner considers that, having regard to the criteria specified in section 232, the person should continue to be restrained (s238). A medical practitioner may make an order extending a bodily restraint order using this form, from the end of the period of bodily restraint under the bodily restraint order for a further period (not exceeding 30 minutes).

The medical practitioner cannot extend the

bodily restraint order unless immediately before doing so, the medical practitioner examines the person (s234).

Criteria for

authorising bodily restraint:

Bodily restraint can be authorised when (s232):

The person needs to be restrained to:

o provide the person with treatment; or o prevent the person from physically injuring themselves or another person; or o prevent the person from persistently causing serious damage to property; and there is no less restrictive way of providing the treatment or preventing the injury or damage; and the use of bodily restraint on the person is unlikely to pose a significant risk to the person's physical health.

Checklist of

Mental Health Act 2014

requirements related to this form:

Give the person a copy of this form as soon as

practicable.

File this form on the person's medical record.

Email a copy of this form to the Chief Psychiatrist at monitoring@ocp.wa.gov.au as soon as practicable and file a record of having done this. If the person is a mentally impaired accused, email a copy of this form to the Mentally Impaired Accused Review Board at prisonersreviewboard@justice.wa.gov.au and file a record of having done this. Notesquotesdbs_dbs31.pdfusesText_37

[PDF] FORM 10E – RECORD OF EXAMINATION OF RESTRAINED

March 2016

CHIEF PSYCHIATRIST

WESTERN AUSTRALIA

WA MENTAL HEALTH

ACT 2014

Please use ID label or block print

FAMILY NAME

GIVEN NAMES

BIRTHDATE

GENDER

ADDRESS

SECTIONS: 234, 238

POSSIBLE EXTENSION OF BODILY RESTRAINT

Results of examination:

Continue until it expires.

Be extended.

Time: HH:MM

Time: HH:MM

Reasons for extending order:

If person has been restrained for a total

If additional space is needed (ie

FORM 10E

RECORD OF EXAMINATION OF RESTRAINED PERSON AND

EXTENSION OF BODILY RESTRAINT

March 2016

When to use this form:

The medical practitioner cannot extend the

Criteria for

Bodily restraint can be authorised when (s232):

The person needs to be restrained to:

Checklist of

Mental Health Act 2014

Give the person a copy of this form as soon as

File this form on the person's medical record.