Daily Record Form – Julian Lezama Farfan

Julian Lezama Farfan








  • MM slash DD slash YYYY

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  • Morning Afternoon Evening Night  
  • • 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?
  • Specify support required and why, and how Client engaged. Detail support required in between sessions relating to each.
  • OT goals will be fatigue management, vocational rehab (study and volunteering), develop a social network/ independent with leisure time and hobbies
  • Temper/ behavioural outbursts complete a separate ABC, note here if separate ABC completed
  • 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.
  • 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.
  • 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.
  • Note difficulty with memory, insight into needs and risks, confusion, and any other cognitive difficulties observed, and strategies used to assist
  • e.g. hydro, gym, note client ability / any problems / needed prompting | Prompt Level
  • 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?
  • 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?
  • 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?
  • 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
  • If concern – who did you contact – CM/ OT etc
  • If concern – who did you contact – CM/ OT etc
  • If concern – who did you contact – CM/ OT etc
  • 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 CM/ACM