RESTRAINT CHARTING 

Student's Name__________________ __________________  Date ___________


Restraint Initiation: 
Date/Time restraint applied:
Is there a current restraint order in the health record?
Reassessment:
What was the behavior that required the restraints?
What alternatives to restraints were attempted first?
Type of restraint(s) utilized:
The determination as to whether or not side rails would be considered a restraint is based on “intent.” 
Therefore:

If the intent of raising the side rails is to prevent a patient from voluntarily getting out of bed or attempting to exit the bed, the side rails would be considered a restraint.

If the intent of raising the rails is to prevent the patient from inadvertently falling out of bed, then it is not considered a restraint. Also, if a patient does not have the physical capacity to get out of bed regardless if side rails are raised or not, then the use of side rails is not considered a restraint. from Joint Commission website.
Assessed orientation
Assessed circulation of the area(s) that is/are restrained
 Does the patient still need restraints?
Assessed sensation of the area(s) that is/are restrained
Yes
No
Yes
No
Interferes with medical devices, tubes, and/or dressings
Confused
Risk for falls
Harmful to self or others
Combative
Unaware of limitation
1:1 Communication
Comfort measures
Frequent toileting
Bed alarm utilized
Nonessential lines/tubes removed
Frequent reorientation
Frequent observation
Utilizing a sitter
Soft limb restraintsLeather or Locked restraintsSeclusion
Wrist restraints
Ankle restraints
Right
Left
Right
Left
Mittens
Vest
Upper body
Lower body
Immobolizer
Chemical
Enclosed bed
Restraints released to provide activity and reapplied
Restraints continued without activity
Restraints removed
Yes
No
Yes
No
Patient oriented, calm, cooperativePatient confused
Yes
No
Pulses present
Capillary refill < 3 sec. to restrained areas
Patient is free from pain
Least restrictive restraint is in use and applied properly