» Daily Record Form

Name of Support Worker*

First

Last

Date of Support Session*

Time shift started*

:

Please use 24hr clock

Time shift ended*

:

Please use 24hr clock

Mood and Fatigue

1. Please describe Madysun’s mood on arrival and throughout your shift. Please consider factors such as pain, distractions, frustrations.*

2. Please rate Madysun’s level of fatigue on a scale of 1 – 5, where 0 is not fatigued and 5 is very fatigued.*

Please describe what factors have affected Madysun’s fatigue level and why.

Activities

3. Has Madysun used her visual timetable to support her to structure her day today?*

4. Please describe how Madysun has used the timetable. E.g. (frequency, level of support throughout the day) Please comment if relevant.*

5. Please outline Madysun’s day, describing activities and the structure of the day.*

6. What time did Madysun get up, did you support her with morning personal care? Please describe, including information relating to; breakfast, getting dressed, getting bags ready.*

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

8. Does a body map need completing? Has this been sent to the appropriate person? If ‘No’, please explain why.*

9. Is a PPE order required? If so, what is to be ordered? Have the Case Management Team been informed?*

10. Did Madysun engage with meal preparation today?*

Yes
No

11. What level of support was required for this? Please describe.*

12. Please describe any social or community-based activity that Madysun took part in today e.g. seeing family, shopping, etc

13. Were there any appointments today? Please Provide Details.

14. Have any new confirmed appointments been added to the diary? Please Provide Details.*

15. Please describe evening routine and activities including bedtime routine. Consider factors such as whether Madysun independently initiated any activity, what prompts were given, level of support given etc.

Therapies

16. Was Madysun seen by any of her therapists today?*

Yes
No

17. If not, did you support Madysun to engage in her treatment plan goals today?*

18. Please also detail any responses, progress or deterioration in the relevant department i.e. PHYSIO, OT, SALT etc. This is so therapists can monitor changes.*

Mobility

19. Please comment on any environmental factors that have posed a risk of safety to Madysun today. e.g. slips, trips, falls, burns etc Inside the Home / Outside the Home.*

Memory and Communication

20. Please describe Madysun’s ability to communicate today. Consider her ability to express herself. Please describe any challenging behaviour observed today.*

21. Has Madysun had a bowel movement during your shift today? Please comment*

Other

22. Any other comments*