Daily Record Form - J L F - CM284 - Stokes Case Management

Daily Record Form – J L F – CM284

Julian Lezama Farfan

Name of Support Worker*

First

Last
Date of Support Session*

MM slash DD slash YYYY
Time Shift Started*

:
Hours

Minutes
Time Shift Ended*

:
Hours

Minutes
Staff on Shift | Note Times*

Morning Afternoon Evening Night
1. Activities & Daily Living Skills
Specify what activities have been done and document details on how Client engaged. Specify support required and why. Who generated the idea about the activity? Did the client have any difficulties initiating or planning the task? How did each activity fit in the day from a time point of view? Did you need to prompt regarding essential activities eg study? How did the client fill his time when support was not with him?*
2. Diet & Nutrition
• Does the client plan his meals (in advance?)
• How much time/ effort does it take to plan meals?
• How does the client budget for purchases?
• Does fatigue effect his ability to cook for himself?
• Does he bulk cook or prepare a meal from scratch every day?
Breakfast*
Lunch*
Dinner*
Water*
Other Fluids*
Other Food*
3. Therapy Input
Specify support required and why, and how Client engaged. Detail support required in between sessions relating to each.
Occupational Therapy*

OT goals will be fatigue management, vocational rehab (study and volunteering), develop a social network/ independent with leisure time and hobbies
Neuropsychology*
Physiotherapy*
Speech and Language Therapy*
4. Fatigue Management
How was the clients sleep – what time did he go to bed/ what time did he go to sleep/ how many times did he wake?/ what time did he awake in the morning/ what time did he get up?*
How was the clients fatigue – grade 1-10 morning, midday, evening 1=minimal fatigue – 10=complete fatigue*
How did fatigue present? – eg started out with headache, progressed to slurred speech, drooping eye?*
When did client realise they were fatigued?*
Did client need prompts to rest? – how long did he rest? what type of rest?*
5. Behaviour / Mood (include times of happiness)/ Anxiety
Temper/ behavioural outbursts complete a separate ABC, note here if separate ABC completed
Morning*

What was the antecedent to the mood change – what happened prior?
Was the client able to resolve independently or was support required? Describe support required.
Afternoon*

What was the antecedent to the mood change – what happened prior?
Was the client able to resolve independently or was support required? Describe support required.
Evening*

What was the antecedent to the mood change – what happened prior?
Was the client able to resolve independently or was support required? Describe support required.
6. Cognitive Observations
Note difficulty with memory, insight into needs and risks, confusion, and any other cognitive difficulties observed, and strategies used to assist
Attention – distractibility, focus, ability to avoid distractions*
Memory – prospective (appointments), medication, using reminders, recall of information provided by lecturers etc*
Awareness of fatigue/ awareness of memory challenges/ awareness of anxiety/ awareness of focus – does the client put strategies in place prior to the difficulty*
Ability to plan day / week*
Ability to structure*
Ability to problem solve*
7. Mobility/Exercise
e.g. hydro, gym, note client ability / any problems / needed prompting | Prompt Level
Morning*

Pain, when comes on – score 1-10. 1=minimal or no pain. 10=absolute worst pain
Does client pre-empt pain or stop after pain experienced?
Doe the pain effect level of energy or engagement in other activities?
Afternoon*

Pain, when comes on – score 1-10. 1=minimal or no pain. 10=absolute worst pain
Does client pre-empt pain or stop after pain experienced?
Doe the pain effect level of energy or engagement in other activities?
Evening*

Pain, when comes on – score 1-10. 1=minimal or no pain. 10=absolute worst pain
Does client pre-empt pain or stop after pain experienced?
Doe the pain effect level of energy or engagement in other activities?
8. 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
Morning*

If concern – who did you contact – CM/ OT etc
Afternoon*

If concern – who did you contact – CM/ OT etc
Evening*

If concern – who did you contact – CM/ OT etc
9. Staff Contact with Clients family*
10. 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
11. Incidents/Accidents*
Brief description – Fill in form and email to CM/ACM
12. Risks and action taken to minimise them
13. Staff Contact with Primary Health/Social Care Services regarding Client and any appointments
14. Health & Safety – have any hazards been reported / identified?
15. Any Other Feedback

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Morning	Afternoon	Evening	Night