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Daily Record Form - LP - CM369 - Day Shift
Daily Record Form – LP – CM369 – Day Shift
Name of Support Worker
*
First
Last
Date of Support Session
*
MM slash DD slash YYYY
Time shift started
*
:
Hours
Minutes
Please use 24hr clock
Time shift ended
*
:
Hours
Minutes
Please use 24hr clock
1. What time did Llewie get up?
2. What is planned for today’s shift i.e. physio/OT/SLT/outing/activity/appointment/school? (please delete as appropriate).
3. How did Llewie engage with the planned activity(s) (on a scale of 1-10, 10 being fully engaged) please select:-
*
1
2
3
4
5
6
7
8
9
10
Comments
4. How did you manage/promote engagement? (i.e. behaviour management plan/SLT treatment plan/OT treatment plan)
5. Did you have any concerns about Llewie’s physical/emotional/behavioural today? Yes/no
Yes
No
If yes did you alert Khloe/case manager/case manager assistant? (delete as appropriate) and note outcome incident form completed/GP contacted/other (please specify below)
6. What did Llewie eat during your shift? Note reaction to food given (i.e. particularly enjoyed/disliked support provided to eat).
7. How did you incorporate MDT goals/treatment plans into Llewie’s day:-
8. Did you complete fluid chart? Are Llewie’s fluid intake and urine output balanced? Yes/no
Yes
No
If no what action have you taken? i.e. informed mum/CM/CMA
9. Did you ask mum if additional dioralyte is required? Yes/no
Yes
No
Comments
10. Is Llewie’s stool 6 or 7 on the Bristol Stool Chart? Yes/no
Yes
No
If no have your reported and to whom?
11. Any signs of UTI? Yes/no
Yes
No
If YES have you reported it?’
12. What was Llewie’s stoma losses?
If over 20ml/kg did you contact mum and replace fluid/seek hospital advice (delete as appropriate).
If hospital advice sought please provide details of advice given:-
13. What is planned for next shift who is taking over from you and have you communicated plan to next carer?
14. Did you give Llewie his meds? Yes/no
Yes
No
If no please state why.
15. If yes, Did you complete the MARS chart? Yes/no
Yes
No
Comments
16. Have you completed the daily task form? Yes/no
Yes
No
Comments