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Run: Restraint Consent and Monitoring Form

A restraint consent and monitoring form for documenting why restraint was used, who authorized it, how consent was handled, and what monitoring occurred unti...

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Event Details

Date of Event (required)

Time of Event (required)

Person Identifier (required)

Use the minimum necessary identifier for the record, such as resident ID or medical record number. Do not collect more PII than needed.

Location (required)

Type of Restraint Event (required)

Describe Other Event Type (required)

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? (required)

Consent Method (required)

Consent Obtained By (required)

Emergency Basis for Restraint (required)

Explain the immediate safety risk and why restraint was necessary without prior consent.

Authorized By (required)

Restraint Details

Reason for Restraint (required)

Least Restrictive Alternatives Attempted (required)

Restraint Type (required)

Describe the Restraint Used (required)

Include the body area involved, device or technique used, and any safety precautions.

Start Date and Time (required)

End Date and Time

Monitoring Record

Monitoring Frequency (minutes) (required)

Monitoring Checks (required)

Additional Monitoring Notes

Release and Review

Were release criteria met? (required)

Post-Event Condition (required)

Adverse Effects or Complications

Document any skin injury, respiratory issues, escalation, or other complications.

Post-Event Review Summary (required)

Submitter and Audit Trail

Submitted By (required)

Submitter Role (required)

Acknowledgment and Signature (required)

I confirm the information in this record is accurate and complete to the best of my knowledge.

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Email (required)

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