Restraint Consent and Monitoring Form

Captures informed consent, justification, monitoring, and release documentation for physical restraint use.

Event Details

• Date of Event
• Time of Event
• Person Identifier
  Use the minimum necessary identifier for the record, such as resident ID or medical record number. Do not collect more PII than needed.
• Location
• Type of Restraint Event
• Describe Other Event Type

Consent and Authorization

• Consent and Disclosure Statement
  This form collects limited PII for clinical and safety documentation. Information will be used for care, compliance, and audit trail purposes only, consistent with organizational policy and applicable law.
• Was informed consent obtained before restraint use?
• Consent Method
• Consent Obtained By
• Emergency Basis for Restraint
  Explain the immediate safety risk and why restraint was necessary without prior consent.
• Authorized By

Restraint Details

• Reason for Restraint
• Least Restrictive Alternatives Attempted
• Restraint Type
• Describe the Restraint Used
  Include the body area involved, device or technique used, and any safety precautions.
• Start Date and Time
• End Date and Time

Monitoring Record

• Monitoring Frequency (minutes)
• Monitoring Checks
• Additional Monitoring Notes

Release and Review

• Were release criteria met?
• Post-Event Condition
• Adverse Effects or Complications
  Document any skin injury, respiratory issues, escalation, or other complications.
• Post-Event Review Summary

Submitter and Audit Trail

• Submitted By
• Submitter Role
• Acknowledgment and Signature
  I confirm the information in this record is accurate and complete to the best of my knowledge.