» Daily Record Form

Name of Support Worker*

First

Last

Name of Support Worker*

First

Last

Date of Support Session*

Session Start time*

:

Please use 24hr clock

Session End time*

:

Please use 24hr clock

1. Have staff read and signed the communication book, and checked/responded to emails and house diary?*

Yes
No

If 'No', please explain why

2. Have staff checked both mobile and house phone for messages?*

Yes
No

If 'No', please explain why

SLEEP

3. What time did K wake up, go to bed, get to sleep and number of times she woke in the night. Please provide details?*

4. Did K do her planned physio and floor exercises today?*

Yes
No

If 'No', please explain why

MEDICATION

5. Did K have all of her prescribed medication today?*

Yes
No

If 'No', please explain why

6. Did she require any PRN? Please detail.*

7. Has the MAR sheet been completed?*

Yes
No

If 'No', please explain why

8. Have the meds count been completed and signed by two members of staff? Is there anything to report, if so have all relevant procedures been taken? Who has been contacted?*

9. Have there been any changes in medication?*

Yes
No

If 'Yes' or 'No'. Please provide information.

FINANCES

10. Have all money checks been completed and signed by two members of staff? ?*

Yes
No

If 'No', please explain why

11. Have all finance/expenditure sheets been completed and signed?*

Yes
No

If 'No', please explain why

12. Are there any issues that need reporting regarding finance/expenditure?*

HOUSEHOLD DUTIES

13. Has the cleaning chart been completed?*

Yes
No

If 'No', please explain why

14. Please provide details of any household duties that K has been able to achieve, and what level of support was required? Initially maybe aim for one per day; laundry, watering plants etc.*

15. Apart from the daily essential duties, bathroom & toilets cleaned, bins and recycling out. List two more chores that staff have completed today, (please remember that mopping is to be done by live-in staff only when K is sleeping).*

FLUIDS

16. Has the fluid chart been completed today (please see inside kitchen cupboard door)?*

Yes
No

17. Please transfer the information below, detailing all of her drinks today.

18. Has K had any urinary problems today? Have you noticed any sign of infection such as smell or dark colour?*

BOWELS

19. Did K open her bowels today and has the bowel chart been completed. Please provide the bowel chart information below.*

MEALS

20. What did K have for breakfast?*

a. How much of her meal did she eat?*

21. What did K have for lunch?*

a. How much of her meal did she eat?*

22. What did K have for supper?*

a. How much of her meal did she eat?*

23. Did K have any snacks today? Please give details*

24. Were there any issues around mealtimes, if so how were they managed? Please detail strategies that worked well and those that didn't*

25. Are there any safeguarding issues that need reporting?

Yes
No

If so where has this been documented and have the correct procedures been followed, who has been informed?

26. Has K's mood and behaviour chart been completed, please detail anything relevant or important. Also include details of strategies used by staff, what worked well what didn't and anything we can learn from each other to help K and her team to progress?*

27. Weekly weight check… For Tuesday staff 'Every Tue Kerry is weighed, has this been completed and please provide her weight below.*

TREATMENT PLAN / GOALS

28. Please summarize below any therapist treatment and goals that have been completed today, also including here any and activities that Kerry has done from her daily planner board. Is there anything you feel needs tweaking on Kerry's planner board?*

29. Please also detail any responses, progress or deterioration in the relevant file ie Physio, OT, SALT etc. So that therapists can monitor changes.*

30. If this is the last shift of the month then have the following been scanned and emailed to Lauren at Lauren@stokescasemanagement.co.uk. This months finance sheets. Mar charts.

FOOD

31. Sunday staff only, Please confirm if the weekly menu has been completed with Kerry?'*

Yes
No

If 'No', please explain why

32. Have used by dates been checked today, if not why not.*

Yes
No

If 'No', please explain why

33. Have any requirements been added to the shopping list?*

Yes
No

If 'No', please explain why

PERSONAL CARE

34. Did K have a bath/shower/strip wash today? If not please detail reasons.*

35. Were there any health issues today? If yes please provide details of health issues below, who has been informed and the actions required.*

Yes
No

Please provide details if applicable.

36. Does a body map need completing? Has this been sent to the appropriate person?*

Yes
No

If 'No', please explain why

37. Did K make or receive any phone calls today? Who? What time? Any relevant details? K's mood after call?

38. Were there any visitors to the house today?*

Yes
No

Comment if neccessary

39. Were they planned?*

Yes
No

If 'No', please explain why

40. Who came, how long for, K's mood afterwards (any changes noticed)*

41. Are there any orders required or been made for PPE? Has the team leader been informed?*

Yes
No

If 'No', please explain why

MOBILITY

42. Have you noticed any changes (progressions/deterioration) in K's mobility today? Transfer's, walking with crocodile frame, any near misses?*

43. Have you noticed any changes (progressions /deterioration) in K's speech today? Slurred words etc.*

44. Did K wear her glasses while using her crocodile frame today? If no, why not?*

45. Did Kerry access the community today, if yes please detail where, how long for and why?*

Yes
No

If 'Yes' or 'No', please explain why.

46. Where, How long, Why, Was it K's choice?

47. Were there any appointments today? Have any new confirmed appointments been added to the diary? Provide details

48. Did K have any rest time? (low stimulus)*

Yes
No

If 'No', please explain why

49. Is there anything you feel needs tweaking on K's planner board?*

Yes
No

If 'No', please explain why

50. Sunday shift staff only. Was the weekly car check completed today? Oil, lights, windscreen wash, tyres etc. Is there anything to report?

Please can both members of staff read and sign. Please submit form at 19:45 daily.

Signed By*

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Signed By*

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