» Daily Record Form

Daily Record Form – EP

Date of Support Session*

MM slash DD slash YYYY
Staff on Shift*

24hr shift
1. Personal Care
shower, wash, note skin breakdowns
2. Health general health, mood changes
3. 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
Please list all work completed on shift by SW (including reference to goals, ADL’s etc).
Morning
08.00am
09.00am
10.00am
11.00am
12.00am
Afternoon
1.00pm
2.00pm
3.00pm
4.00pm
5.00pm
6.00pm
Evening
7.00pm
8.00pm
9.00pm
10.00pm
11.00pm
07.00am
Time EP awoke? Leave her bed?
Time EP got out of bed?
Time EP went to bed
4. Fatigue Management (Please note EP’s rest periods, with times)
5. Hoarding/ overspending concerns
6. Any concerns regarding medication?
7. Guidelines for staff to fill in EPs food drink of day. Complete Yes/No?
- Yes
- No
Comment if neccessary
a. Staff involved EP in decision with food planning. Yes/No?
- Yes
- No
Comment if neccessary
b. Food wastage. Yes/No?
- Yes
- No
Dinner
c. Has a food diary been completed. Yes/No?
- Yes
- No
Comment if neccessary
8. 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
Physiotherapy
Other
9. Mobility / Exercise / Activities & Daily Living Skills
Specify what activities have been done and document details on how CLIENT engaged. Record prompt level. Refer to OT Guidelines.
10. Goals
Select if client and team have worked towards their goals
- Select All
- 1. Weight management and healthy eating: Summary of days healthy eating
- 2. Tasks EP is undertaking independently- opening and closing curtains, independent overnight with SW in room nearby, and her phone/walker etc to hand
- 3. Technology
Comment if neccessary
Did EP stick to plan of healthy ? Tick Yes or No?
- Yes
- No
If 'No', staff to discuss slip in diet and what treats had. Staffs support given to re-engage EP to think about her diet?
11. Care Plans
Actions or Practice as Specified in Care Plan Guidelines – detail how client and team have followed their care plans
12. Behaviour / Mood (include times of happiness, anxiety)

Temper/ behavioural outbursts complete a separate ABC, note here if separate ABC completed
Morning
Afternoon
13. Cognitive Observations

Record any observed cognitive difficulties below and strategies used to assist
Memory
Initiation
Insight
Planning
Problem Solving
Information processing
Anxiety
Any other cognitive observations:
14. Staff Contact with Clients family
15. Staff/client Contact with Primary Health/Social Care Services regarding Client and any appointments
**Ensure appointment form is filled out in addition to this box when EP attends Dr appointments. Reminder needs to be sent to Stoke.
16. None 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
17. Incidents/Accidents
Brief description – Fill in form and email to TM/CM
18. Risks and action taken to minimise them
19. Changes to Medication

Medication Dosage Time Reason for change

(Please state reductions in medications, PRN given, please log when medication delivered from chemist)
20. Nights
21. Any Other Feedback
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
* Prompt levels: 1 = no prompt / 5 = full prompt

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Registered in England & Wales Company number: 09125760

Registered office: Villa House 7 Herbert Terrace, Penarth CF64 2AH

24hr shift

Medication	Dosage	Time	Reason for change

Daily Record Form – EP

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