» Daily Record Form

Date of Support Session*

Staff on Shift*

Staff Name

Times

Staff on Shift

Staff Name

Times

Staff on Shift

Staff Name

Times

1. Changes to Medication (Please state reductions in medications, PRN given, please log when medication delivered from chemist*

Yes
No

Medication | Dosage | Time | Reasons for change

2. Diary

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*

Afternoon*

Evening*

3. Fatigue Management (Any observed or reported instances of fatigue and what support was provided)*

4. Activities & Daily Living Skills Specify what activities have been done and document details on how CLIENT engaged. Record prompt level. Refer to OT Guidelines.*

Prompt levels: 1 = no prompt / 5 = full prompt

Comments

5. Diet & Nutrition: CM specify level of support HERE*

Prompt levels: 1 = no prompt / 5 = full prompt

Breakfast*

Lunch*

Dinner*

Water*

Other Fluids*

Other Food*

6. Mobility/Exercise e.g. hydro, gym, note client ability / progress*

Prompt levels: 1 = no prompt / 5 = full prompt

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*

Prompt levels: 1 = no prompt / 5 = full prompt

Memory:*

Initiation:*

Insight:*

Planning:*

Problem solving:*

Information processing:*

Anxiety:*

Any other cognitive observations:*

11. Staff Contact with Clients family*

12. 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

13. Incidents/Accidents*

Brief description - Fill in form and email to CM/ACM.

14. Risks and action taken to minimise them*

15. Staff Contact with Primary Health/Social Care Services regarding Client and any appointments.*

Additional information

Daily Record Form - GC