» Daily Record Form – KB DAY SHIFT

Name of Staff member completing the form*

First Name

Last Name

Please select Agency or DP staff

Names of all staff on shift*

Please select Agency or DP staff

Date of Support Session*

Session Start time*

:
HH

MM

Please use 24hr clock

Session End time*

:
HH

MM

Please use 24hr clock

Daily Diary AM

Did Kyle have a wash this morning? Yes / No. Please comment.

Did Kyle go in the standing frame this morning? Yes / No. Please comment.

Did you brush Kyles teeth after lunch? Yes / No. Please comment.

1. Did you give Kyle a choice of activities this morning?

2. What activities did you offer to Kyle to do?

3. How long did Kyle engage in the chosen activities (please also describe home Kyle participated and what level of support he needed)

4. Please describe Kyles mood this morning.

5. Please describe Kyles communication this morning.

6. Were there any health concerns or seizure activity?

7. Were there any inappropriate verbal or physical behaviours (such as offensive words and names directed at people, hitting, pinching, poking, slapping of people) ? Yes / No. Please comment. (if so please complete behaviour monitoring form at the end of this form in detail)

8. Has all medication this morning been given and all guidelines followed. Yes / No. Please comment.

9. Did Kyle do his morning exercise routine today? Yes / No. Please comment.

Daily Diary PM

1. Did you give Kyle a choice of activities this afternoon?

2. What activities did you offer to Kyle to do?

3. How long did Kyle engage in the chosen activities (please also describe home Kyle participated and what level of support he needed)

Was the infection control cleaning routine carried out?

4. Please describe Kyles mood this afternoon.

5. Please describe Kyles communication this afternoon.

6. Were there any health concerns or seizure activity?*

If yes to seizure activity please record how long it lasted for and describe the seizure

Was any ‘short term’ or ‘time limited’ medication (such as the antibiotics) administered today: Yes/No. Please comment

7. Did you brush Kyles teeth after dinner? Yes / No. Please comment.

8. Did you give all afternoon medication?

9. Temperature for AM and PM recorded on Mar chart? Yes / No. Please comment.

10. Did Kyle open his bowels? Yes / No. Please comment.

11. Fluid intake (please write as approx ml)

DAILY DIARY – NUTRITION AND HYDRATION

Breakfast

1. Food Offered (include consistency), Comments (held in mouth, choked, coughed) and Amount Eaten*

2. Was KB able to feed himself for part of the meal? How long? What equipment did he use? Please comment.*

3. Drink Offered, Amount (mls) thickend and unthickend. Comments (held in mouth, choked, coughed)*

4. Did KB request drinks or say he was thirsty?

Yes
No

5. Did KB manage to carry out drinking independently at any time, participate actively in the task. Please comment.*

Lunch

6. Food Offered (include consistency), Comments (held in mouth, choked, coughed) and Amount Eaten*

7. Was KB able to feed himself for part of the meal? How long? What equipment did he use? Please comment.*

8. Drink Offered (after breakfast), Amount (mls) and Comments (held in mouth, choked, coughed)*

9. Did KB request drinks or say he was thirsty?

Yes
No

10. Did KB manage to carry out drinking independently at any time, participate actively in the task. Please comment.*

Dinner

11. Food Offered (include consistency), Comments (held in mouth, choked, coughed) and Amount Eaten*

12. Was KB able to feed himself for part of the meal? How long? What equipment did he use? Please comment.*

13. Drink Offered (after breakfast), Amount (mls) and Comments (held in mouth, choked, coughed)*

14. Did KB request drinks or say he was thirsty?

Yes
No

15. Did KB manage to carry out drinking independently at any time, participate actively in the task. Please comment.*

Comments

Snacks

16. Please comment on snacks and the time these were offered.

17. Was KB able to feed himself for part of the snack? How long? What equipment did he use? Please comment.

DAILY DIARY – CHECKLIST

Household Tasks (please tick if you have completed)*

Laundry
Ironing
Hoovering/Mopping
General Cleaning
KB’s Dishes etc

DAILY GOALS

Record daily/weekly goals following discussions with KB.

Below are Behaviour Monitoring Forms. Please only complete these if Kyle has displayed any inappropriate physical or verbal behaviours that are identified on the list below…… Please complete one form for each behaviour

BEHAVIOUR MONITORING FORM

1. Describe in detail the behaviour (i.e. raised left hand and punched wall, used right arm and quickly lunged forward to grab me, threw object, swore at me…)

2. List any significant events which have occurred within the last 24 hours (i.e. call from mother, visits from people, conflict with another person, physical discomfort / ill health)

3. Please tick the phrase(s) that best describe the environment at the time the behaviour occurred:

4. Names of all people who were around at the time of the behaviour

5. Describe what the person was actually doing at the time the behaviour started (what activity was the person doing as the behaviour started?)

6. What happened IMMEDIATELY before the behaviour? (What may have set off the behaviour? Was there a loud noise, was the person asked to do something, had something given to them…)

Completed By

Date & Time

This form MUST be completed following ANY incidents of difficult behaviour, along with accident book and Health & Safety incident form if required.

BEHAVIOUR MONITORING FORM

1. Describe in detail the behaviour (i.e. raised left hand and punched wall, used right arm and quickly lunged forward to grab me, threw object, swore at me…)

2. List any significant events which have occurred within the last 24 hours (i.e. call from mother, visits from people, conflict with another person, physical discomfort / ill health)

3. Please tick the phrase(s) that best describe the environment at the time the behaviour occurred:

4. Names of all people who were around at the time of the behaviour

5. Describe what the person was actually doing at the time the behaviour started (what activity was the person doing as the behaviour started?)

6. What happened IMMEDIATELY before the behaviour? (What may have set off the behaviour? Was there a loud noise, was the person asked to do something, had something given to them…)

Completed By

Date & Time

This form MUST be completed following ANY incidents of difficult behaviour, along with accident book and Health & Safety incident form if required.

BEHAVIOUR MONITORING FORM

1. Describe in detail the behaviour (i.e. raised left hand and punched wall, used right arm and quickly lunged forward to grab me, threw object, swore at me…)

2. List any significant events which have occurred within the last 24 hours (i.e. call from mother, visits from people, conflict with another person, physical discomfort / ill health)

3. Please tick the phrase(s) that best describe the environment at the time the behaviour occurred:

4. Names of all people who were around at the time of the behaviour

5. Describe what the person was actually doing at the time the behaviour started (what activity was the person doing as the behaviour started?)

6. What happened IMMEDIATELY before the behaviour? (What may have set off the behaviour? Was there a loud noise, was the person asked to do something, had something given to them…)

Completed By

Date & Time

This form MUST be completed following ANY incidents of difficult behaviour, along with accident book and Health & Safety incident form if required.

BEHAVIOUR MONITORING FORM

1. Describe in detail the behaviour (i.e. raised left hand and punched wall, used right arm and quickly lunged forward to grab me, threw object, swore at me…)

2. List any significant events which have occurred within the last 24 hours (i.e. call from mother, visits from people, conflict with another person, physical discomfort / ill health)

3. Please tick the phrase(s) that best describe the environment at the time the behaviour occurred:

4. Names of all people who were around at the time of the behaviour

5. Describe what the person was actually doing at the time the behaviour started (what activity was the person doing as the behaviour started?)

6. What happened IMMEDIATELY before the behaviour? (What may have set off the behaviour? Was there a loud noise, was the person asked to do something, had something given to them…)

Completed By

Date & Time

This form MUST be completed following ANY incidents of difficult behaviour, along with accident book and Health & Safety incident form if required.

BEHAVIOUR MONITORING FORM

1. Describe in detail the behaviour (i.e. raised left hand and punched wall, used right arm and quickly lunged forward to grab me, threw object, swore at me…)

2. List any significant events which have occurred within the last 24 hours (i.e. call from mother, visits from people, conflict with another person, physical discomfort / ill health)

3. Please tick the phrase(s) that best describe the environment at the time the behaviour occurred:

4. Names of all people who were around at the time of the behaviour

5. Describe what the person was actually doing at the time the behaviour started (what activity was the person doing as the behaviour started?)

6. What happened IMMEDIATELY before the behaviour? (What may have set off the behaviour? Was there a loud noise, was the person asked to do something, had something given to them…)

Completed By

Date & Time

This form MUST be completed following ANY incidents of difficult behaviour, along with accident book and Health & Safety incident form if required.