Patient Restraint Assessment & Monitoring Checklist
Document comprehensive assessment and ongoing monitoring of patients in restraints per CMS Conditions of Participation and Joint Commission standards.
- Industry: Healthcare
- Frequency: Every 2 hours / Per policy
- Estimated Time: 10-15 minutes
- Role: Nurse
- Total Items: 28
- Compliance: CMS CoP 42 CFR 482.13, Joint Commission PC.03.05.01-17, State Regulations
Order Verification
Verify valid restraint order
- Current valid restraint order in place?
- Order within time limits (4h adult, 2h peds)?
- Physician face-to-face within 1 hour (if behavioral)?
- Least restrictive restraint being used?
Physical Assessment
Patient physical status
- Circulation to extremities adequate?
- Skin integrity intact under/around restraint?
- Range of motion maintained?
- Vital signs within acceptable limits?
- Nutrition/hydration needs addressed?
- Elimination needs addressed?
Behavioral Assessment
Patient behavioral status
- Current behavior documented?
- Orientation level assessed?
- Patient response to restraint documented?
- Agitation/anxiety level assessed?
Alternatives Considered
Less restrictive alternatives
- Verbal de-escalation attempted?
- Environmental modifications considered?
- Family presence considered?
- Distraction techniques attempted?
- Continued need for restraint documented?
Restraint Device Check
Device safety verification
- Restraint properly applied?
- Two-finger space under restraint?
- Quick-release knots used?
- Tied to bed frame (not rails)?
Pre-Assessment Information
Initial assessment documentation and patient/facility identification
- Assessor Name / Credentials
- Assessment Date
- Department / Unit
- Assessment Type (Routine/Annual/Complaint)
- Previous assessment findings reviewed?
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Why Use This Patient Restraint Assessment & Monitoring Checklist?
This patient restraint assessment & monitoring checklist helps healthcare teams maintain compliance and operational excellence. Designed for nurse professionals, this checklist covers 28 critical inspection points across 6 sections. Recommended frequency: every 2 hours / per policy.
Ensures compliance with CMS CoP 42 CFR 482.13, Joint Commission PC.03.05.01-17, State Regulations. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the Patient Restraint Assessment & Monitoring Checklist cover?
This checklist covers 28 inspection items across 6 sections: Order Verification, Physical Assessment, Behavioral Assessment, Alternatives Considered, Restraint Device Check, Pre-Assessment Information. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed every 2 hours / per policy. Each completion takes approximately 10-15 minutes.
Who should use this Patient Restraint Assessment & Monitoring Checklist?
This checklist is designed for Nurse professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.