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Daily Record Form - EP - CM305
Daily Record Form – EP – CM305
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. Daily Activites / Diary
Include changes in the clients 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).
4. Night Care
Time EP awoke? Time EP got out of bed? Time EP went to bed. Any other comments
5. Fatigue Management (Please note EPs rest periods, with times)
6. Medication administration/ Signing of MAR
7. Have staff recorded Eileens food and drink consumption in the Food Diary? Complete Yes/No?
Yes
No
8. Please add any relevant comments about Eileens eating/ drinking habits i.e., healthy eating, treats etc.
9. Therapy / 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. Trips Out
Please comment whether you accessed the community with EP and if so, where. Please document any research undertaken or plans made.
11. 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
12. Care Plans
Actions or Practice as Specified in Care Plan Guidelines – detail how client and team have followed their care plans
13. Behaviour / Mood (include times of happiness, anxiety)
Temper/ behavioural outbursts complete a separate ABC, note here if separate ABC completed
**Has an ABC form been submitted? Yes/No**
Yes
No
14. Cognitive Observations
Select All
Memory
Initiation
Planning
Insight
Problem Solving
Information Processing
Anxiety
Splitting Behaviours
Please elaborate on Cognitive Difficulties below:
15. Splitting Behaviours
Please record any incidents of splitting behaviours, as well as any communication which could potentially lead to the onset of splitting behaviours. Please ensure you maintain transparent conversation with the team to address such issues.
16. Staff or client contact with client family
17. 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.
18. 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
19. Incidents/Accidents
Brief description – Fill in form and email to TM/CM
20. Risks and action taken to minimise them
21. Changes to Medication
Medication
Dosage
Time
Reason for change
(Please state reductions in medications, PRN given, please log when medication delivered from chemist)
22. Nights
23. 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
