Daily Record Form – EP

  • MM slash DD slash YYYY

  • 24hr shift  
  • shower, wash, note skin breakdowns
  • 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).

  • 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.
  • Specify what activities have been done and document details on how CLIENT engaged. Record prompt level. Refer to OT Guidelines.
  • Select if client and team have worked towards their goals

  • Actions or Practice as Specified in Care Plan Guidelines – detail how client and team have followed their care plans
  • Temper/ behavioural outbursts complete a separate ABC, note here if separate ABC completed
  • Record any observed cognitive difficulties below and strategies used to assist
  • **Ensure appointment form is filled out in addition to this box when EP attends Dr appointments. Reminder needs to be sent to Stoke.
  • Include Matters or Concerns Regarding CLIENTS Health and Well-Being or Requests Made for Assistance Over and Above That Agreed in The Care Plan
  • Brief description – Fill in form and email to TM/CM
  • Medication Dosage Time Reason for change  
    (Please state reductions in medications, PRN given, please log when medication delivered from chemist)
  • 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