Restraints Use Audit

Audit template for reviewing physical and chemical restraint use, including order documentation, least-restrictive alternatives, monitoring, and timely release.

Audit Scope and Episode Identification

• Resident/patient identifier and audit date are documented
• Type of restraint reviewed is identified as physical, chemical, or both
• Relevant charting, orders, and monitoring records were available for review
• Audit episode time frame is clearly defined

Order Documentation and Authorization

• Valid restraint order is present in the record
• Order includes indication or clinical rationale for restraint use
• Order specifies type of restraint and conditions for use
• Order start date and time are documented
• Order duration or renewal interval is documented and within policy
• Ordering provider or authorized clinician is identified

Least-Restrictive Alternatives and Clinical Justification

• Behavioral, environmental, or de-escalation alternatives were attempted or documented as not feasible
• Restraint was the least restrictive intervention appropriate to the situation
• Clinical justification describes the immediate safety risk or medical necessity
• Patient/resident rights, consent, or notification requirements were addressed per policy

Monitoring, Reassessment, and Safety Checks

• Monitoring frequency matches facility policy and order requirements
• Circulation, skin integrity, respiration, and level of distress were assessed and documented
• Vital signs or other required clinical observations were documented when applicable
• Reassessment for continued need was completed at required intervals
• Any adverse effects, escalation, or complications were documented and escalated appropriately

Timely Release and Discontinuation

• Restraint was released at the earliest safe opportunity
• Release time is documented
• Criteria for discontinuation or transition to less restrictive measures are documented
• Post-release assessment confirms patient safety and stability

Audit Findings and Corrective Actions

• Deficiencies or non-conformances identified
• Corrective action plan documented
• Inspector signature