» Daily Record Form

Daily Record Form – DR

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

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Daily Record Form – DR

Records maintained in the client’s home should include the following details as a CQC requirement;