Patient Surname* Patient NHI* Patient requirements*Category A - 1:1, The Patient is within arms length at all times.Category B - Visual Observation, The Patient is within sight at all timesCategory C - Time Specific Observation contact every 10 -20 mins What are the reasons?*ConfusionInfant/Child/Youth Harm PreventionSelf HarmAgitationDisorientatedLack of Co-OperationDrug WithdrawalPost Operative DeliriumHarm to Othersother Contributing factors* Consideration for Cohorting Options*Enter the personal space of other patients or hinder their careRemove essential medical equipment from themselves or othersDisplay unsafe behavior increasing risk of harm e.g. impulsivenessSelf - HarmVerbal or Physical abuse/Threaten othersYes suitable for cohortingInfant/Child Attenderother Contact No (Requestor)* Ward/Department*Select valueWard 1Ward 2Ward 3Ward 4Ward 12Ward 14Ward 15Ward 16CCUICUEDAssessment UnitMaternitySCBURenalBay of Islands Has there been contact made to the patients primary contact.*YesNoSubmitReset