» Daily Record Form – LP

Name of Support Worker*

First

Last

Date of Support Session*

Time shift started*

:

Please use 24hr clock

Time shift ended*

:

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:-*

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

Daily Record Form – LP Day Shift