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Daily Record Form - DR - CM316
Daily Record Form – DR – CM316
Date of Support Session
*
MM slash DD slash YYYY
Staff on Shift
Staff Name
Times
1. Changes to Medication
*
Yes
No
Medication | Dosage | Time | Reasons for change
2. Diary
Include changes in the client’s needs and/or usual behaviour or routine and action taken
Also include unusual or changed circumstances that affect the client – highlight any deviations
Morning
*
Afternoon
*
Evening
*
3. Activities & Daily Living Skills Specify what activities have been done and document details on how CLIENT engaged. Record prompt level. Refer to OT Guidelines.
*
4. Diet & Nutrition: CM specify level of support HERE
Breakfast
*
Lunch
*
Dinner
*
Water
*
Other Fluids
*
Other Food
*
5. Therapy Input Prompt Level needed to complete activity. Refer to Guidelines
Occupational Therapy
Neuropsychology
Physiotherapy
6. Fatigue Managment
*
7. Goals
*
Detail how client and team have worked towards the agreed goals
8. Care Plans
*
Actions or Practice as Specified in Care Plan Guidelines – detail how client and team have followed their care plans
9. Behaviour / Mood (include times of happiness)
Temper/ behavioural outbursts complete a separate ABC, note here if separate ABC completed
Morning
*
Afternoon
*
Evening / Night
*
10. Cognitive Observations
Record cognitive difficulties observed below and strategies used to assist
Memory:
*
Initiation:
*
Insight:
*
Planning:
*
Problem solving:
*
Information processing:
*
Perseveration:
*
Temperature monitoring:
*
11. Mobility/Exercise
e.g. hydro, gym, note client ability / any problems / needed prompting
Morning
*
Afternoon
*
Evening
*
12. Staff Contact with Clients family
*
13. Note any staff or client contact with Team Leader or 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
14. Incidents/Accidents
*
Brief description – Fill in form and email to CM/ACM.
15. Risks and action taken to minimise them
*
16. Staff Contact with Primary Health/Social Care Services regarding Client and any appointments.
*
17. Nights
*
Note sleep hygiene
Any Other Feedback
Records maintained in the client’s home should include the following details as a CQC requirement;
Records maintained in the client’s 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 the client, highlight any deviations Contact between the support worker and primary health/social care services regarding the client Contact with the client’s family or Case Manager or Team Leader 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
