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Daily Record Form - KB DAY SHIFT
Daily Record Form – KB DAY SHIFT
Name of Staff member completing the form
*
First Name
Last Name
Please select Agency or DP staff
Select appropriate
Agency
DP
Names of all staff on shift
*
Please select Agency or DP staff
Select appropriate
Agency
DP
Date of Support Session
*
Date Format: DD slash MM slash YYYY
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?
Select appropriate
Yes
No
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?
Select appropriate
Yes
No
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 and evening 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. 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.
