Restraint Order Form — Hospital Version
Restraint is a last resort with a time limit, a named doctor, a consent record, and a review every four hours — not a decision made and forgotten
What it is
A hospital restraint authorisation and review form. Restraint must be: clinically indicated (risk to patient or others cannot be managed otherwise), ordered by a named doctor, explained to patient and/or family, reviewed every four hours, and discontinued as soon as the indication no longer applies. A restraint applied without a written order, without family notification, and without a review schedule is not governance — it is an unlawful deprivation of liberty in most jurisdictions.
ASF criterion
Evidence for: Hospital Standard 4, criterion 4.23 (Core) — Restraint and Seclusion Use Is Governed and Minimised.
| RESTRAINT AUTHORISATION & REVIEW · ASF-TOOL-EWD-07 | |
|---|---|
| Patient name | |
| DOB / ID / Ward | |
| Date and time of application | |
| Clinical indication (must be documented — “agitated” is not sufficient) | |
| |
|
| Alternatives tried before restraint (must document at least two) | |
| |
|
| Type of restraint applied | ☐ Wrist ☐ Vest ☐ Mittens ☐ Other: |
| Ordering doctor (name + signature) | |
| Patient / family notified | ☐ Yes — by: ☐ Unable (reason): |
| Initial order valid until (max 4 hours) | |
| Four-hourly review (complete every 4 hours while restraint continues) | |
| Time | Indication still present? · Skin intact? · Circulation OK? · Continued? (Y/N + reason) · Reviewer sig. |
| Restraint discontinued: Date/time: Reason: | |
ASF-TOOL-EWD-07 · Toolkit 34 · france-asf.fr/tools · ASF original © Accréditation Sans Frontières · CC BY-NC-SA 4.0 · Legal requirements for restraint vary by jurisdiction — confirm with national law before use · Keep this line on all adapted versions
