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Daily Record Form - C C - CM301 - Day Shift
Daily Record Form – C C – CM301 Day Shift
Date of Support Session
*
MM slash DD slash YYYY
Staff on Shift
*
Morning 08.30am – 12pm
Afternoon 12pm – 7.30pm
1. Any Medication Required?
Medication
Dosage
Time
Additional Information
To record any changes to known medication, for example, a new medication is prescribed – please record why this has been prescribed, name of medication, strength and frequency of medication. Please also add if this prescription is temporary (i.e antibiotics), if so, please record end date.
2. Personal Care/Prompts required?
Please record reasons why nappies or clothing is changed and why clothes have needed to be changed. Please record any instances of personal care provided to Corey in as much information as possible.
3. Diary
This section is used to provide a brief overview of the shift. Please briefly state what was done; there is space in forthcoming sections to provide more detail
Morning
Afternoon
Evening
4. Activities & Daily Living Skills
Please breakdown information recorded in the diary section, providing more detail based on activities of daily living completed.
5. Diet & Nutrition:
List below all nutritional and input as well as fluids. Please report what support the client required to undertake each aspect of the activity. Please comment on what both the client’s limbs were doing during the task.
Breakfast
Lunch
Dinner
Water
Other Fluids
Other Food
6. Continence & Bowels: –
Please record observations and timings. If not observed directly, please write “dad reported” for example. Please also record times and whether these were observed or reported.
7. Therapy Input
Record what happened as determined by therapist guidance on support worker led interventions. Did preparations go ahead as planned? If not, please explain the reasons why. Please refer to what therapeutic goals you supported Corey with today in the goals section.
Occupational Therapy
Neuropsychology
Physiotherapy
Speech and Language Therapy
8. Observations of Fatigue
Please record any observations which could be evidence of fatigue, and whether this was observed or reported. (Examples may include the client yawning or being unable to hold his attention on a task).
9. Vision
Observations of visual abilities. Was equipment in place (optical glasses)? Did you observe any potential visual difficulties?
10. Goals
Corey’s goals are all therapeutic, as recorded in the sections above such as therapy.
11. Care Plans
Please report in this section any deviations from the client’s agreed care plans.
12. Behaviour / Mood observations:
Please record in this section the client’s behaviour and mood throughout your shift. Please include positive and negative instances of behaviour or mood. For behavioural outbursts (challenging behaviour) complete a separate ABC and note here if separate ABC form was completed.
Morning
Afternoon
13. Cognitive Observations
Record any observed cognitive difficulties below and strategies used to assist the client to overcome these. Were strategies effective and did they have the desired effect?
Memory
Initiation
Insight
Planning
Problem Solving
Information processing
Vacant episodes:
(Please also record on seizure monitoring form)
14. Mobility/Exercise
Please comment on the client’s mobility and exercises completed during the shift. Please note client ability / equipment required / set up required / any problems encountered / and determine what prompting was required.
Morning
Afternoon
15. Staff Contact with Clients family
16. Observations of Parents
Report any information in regard to parental fatigue (observed or reported) and other demands on parent’s time (i.e. therapies, visitors, siblings)
17. Note any contact with Case Manager
Include Matters or Concerns Regarding clients Health and Well-Being or Requests Made for Assistance Over and Above That Agreed in The Care Plan.
18. Incidents/Accidents
Brief description – Fill in form and email to TM/CM
19. Risks and action taken to minimise them
20. Staff Contact with Primary Health/Social Care Services regarding Client and any appointments
21. Nights
Note sleep hygiene and what bed he slept in
22. Accommodation
Please report any observed or reported issues with accommodation (i.e. parental reporting of isolation, issues undertaking therapy tasks in the space, etc).
23. Any Other Feedback
