» Daily Record Form

Name of Support Worker*

First

Last
Date of Support Session*

Date Format: MM slash DD slash YYYY
Time shift started*

:
HH

MM

Please use 24hr clock
Time shift ended*

:
HH

MM

Please use 24hr clock
1. Please describe the tasks you completed in relation to EA's personal hygiene.
2. Please describe the tasks you completed in relation to EA's dental hygiene.
3. Toileting – (how often did EA go, did he have a poo or a wee, how much support was required, any incontinence to be recorded).
4. Dressing – did EA select his own clothes, did he support with dressing himself.
5. Behaviour – describe in depth, trigger points, how was his behaviour managed.
6. Mood – describe in depth, trigger points, how was his mood managed.
7. Mobility – how much support was required, describe any risks.
8. Please provide a narrative in regards to the physical assistance required when out in the community.
9. Diet – what did EA eat and drink – did he need any assistance – snacks?
10. Activities – describe what activities EA participated in.
11. Sleep – what time did he go to bed, did he wake , we’re there any challenges , any fatigue throughout the day.

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