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Daily Record Form - MT
Daily Record Form – MT
Date of Support Session
*
MM slash DD slash YYYY
Staff on Shift
*
Staff Name
Times
Staff on Shift
Staff Name
Times
Staff on Shift
Staff Name
Times
1. Changes to Medication (Please state reductions in medications, PRN given, please log when medication delivered from chemist
*
Yes
No
Medication | Dosage | Time | Reasons for change
2. Diary
Diary Include changes in the client’s needs and/or usual behaviour or routine and action taken
Also include unusual or changed circumstances that affect the client – highlight any deviations.
Morning
*
Afternoon
*
Evening
*
3. Activities & Daily Living Skills Specify what activities have been done and document details on how CLIENT engaged. Record prompt level. Refer to OT Guidelines.
*
Prompt levels: 1 = no prompt / 5 = full prompt
1
2
3
4
5
4. Diet & Nutrition: CM specify level of support HERE
*
Prompt levels: 1 = no prompt / 5 = full prompt
1
2
3
4
5
Breakfast
*
Lunch
*
Dinner
*
Water
*
Other Fluids
*
Other Food
*
5. Therapy Input Prompt Level needed to complete activity. Refer to Guidelines
*
Prompt levels: 1 = no prompt / 5 = full prompt
1
2
3
4
5
Neuropsychology
*
Physiotherapy
*
6. Fatigue Management (Any observed or reported instances of fatigue and what support was provided)
*
7. Goals detail how client and team have worked towards the agreed goals
*
8. Care Plans Actions or Practice as Specified in Care Plan Guidelines – detail how client and team have followed their care plans
*
9. Behaviour / Mood (include times of happiness) Temper/ behavioural outbursts complete a separate ABC, note here if separate ABC completed
Morning
*
Afternoon
*
Evening / Night
*
10. COGNITIVE OBSERVATIONS Record cognitive difficulties observed below and strategies used to assist
*
Prompt levels: 1 = no prompt / 5 = full prompt
1
2
3
4
5
Memory:
*
Initiation:
*
Insight:
*
Planning:
*
Problem solving:
*
Information processing:
*
Perseveration:
*
Temperature monitoring:
*
11. Mobility/Exercise e.g. hydro, gym, note client ability / progress
*
Prompt levels: 1 = no prompt / 5 = full prompt
1
2
3
4
5
Morning
*
Afternoon
*
Evening
*
12. Staff Contact with Clients family
*
13. Note any staff or client contact with Team Leader or Case Manager
*
Include Matters or Concerns Regarding CLIENTS Health and Well-Being or Requests Made for Assistance Over and Above That Agreed in The Care Plan
14. Incidents/Accidents
*
Brief description – Fill in form and email to CM/ACM.
15. Risks and action taken to minimise them
*
16. Staff Contact with Primary Health/Social Care Services regarding Client and any appointments.
*
17. Nights Note sleep hygiene
18. Any Other Feedback
