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Daily Record Form - DC - Night Shift
Daily Record Form – DC Night Shift
Name of Support Worker
*
First
Last
Date of Support Session
*
MM slash DD slash YYYY
Time Shift Started
*
:
Hours
Minutes
Time Shift Ended
*
:
Hours
Minutes
1. Pain / Illness
*
Liase with parents to document any pain management techniques delivered- i.e., steps taken to reduce pain and how staff/ parents supported with this, describe how client was consulted, options offered before resulting in administering PRN etc. What was the outcome?
2. Personal Care
*
Showering/bathing/dressing etc. Was support delivered by staff or parents? If so, what care was given? Was this completed as per the Care Plan? Yes or no, (delete as appropriate) if no, please detail why.
3. Nutrition
Liaise with parents to detail what client has eaten and his engagement in preparation/cooking/ making drinks, and any risks identified.
Breakfast
Fluids
4. Bowel Movements AM & PM
Liaise with parents to detail what client has eaten and his engagement in preparation/cooking/ making drinks, and any risks identified.
5. Behaviour/Mood including happiness and positivity.
Also briefly note what Client feels contributed to his happiness or low mood/outburst and staff observations. Temper/ behavioural outbursts complete a separate ABC, note here if separate ABC completed
6. Seizure activity
When did Douglas last have a seizure?
*
Did Douglas have a seizure during your shift? If so, please give details including any intervention made- document seizure diary.
*
Was emergency medication needed?
*
7. Diary
*
Please document patterns of sleep
8. Note any staff or client contact with Team Manager or Case Manager Please liaise with parents
*
Include Matters or Concerns Regarding clients Health and Well-Being i.e., GP/ hospital appointments, or Requests Made for Assistance Over and Above That Agreed in The Care Plan.
9. Incidents/Accidents
*
Brief description – Fill in form and email to CM/ACM
10. Risks and action taken to minimise them
11. T/M or Staff Contact with Primary Health/Social Care Services regarding client and any appointments
12. Any Other Feedback
Staff to include observations on what they felt went really well/felt positive about?
Records maintained in the Clients home should include the following details as a CQC requirement.
* The full name, date and arrival and shift times of every staff member
* Goals, actions, or practice as specified in the care plan
* Changes in the clients needs, usual behaviour or routine and action taken.
* Unusual or changed circumstances that affect Client, highlight any deviations
* Contact between the support worker and primary health/social care services regarding client
* Contact with Clients Team Manager or Case Manager about matters or concerns regarding their health and wellbeing
* Requests made for assistance over and above that agreed in the care plan
* Incidents, ABC’s accidents or near misses and action taken.
* Risks and action taken to minimise them
