» Daily Record Form

Daily Record Form – RB

Date of Support Session*

MM slash DD slash YYYY
Name of Support Worker (DAY TIME)*

First

Last
Time shift started*

:
Hours

Minutes

Please use 24hr clock
Time shift ended*

:
Hours

Minutes

Please use 24hr clock
Name of Support Worker (NIGHT TIME)*

First

Last
Time shift started*

:
Hours

Minutes

Please use 24hr clock
Time shift ended*

:
Hours

Minutes

Please use 24hr clock
1. Were there any changes to medication today?*
- Yes
- No
Comments
2. Mar Chart*
Have staff completed the Mar Chart today?
- Yes
- No
Comments
3. Swallowing*
Note any difficulties with swallowing medication and support required.
4. Goals
Ron has chosen and is supported to follow ‘The Alzheimer’s Solution’ to help him achieve his personal goal to live to the age of 101. His goals are broken down following the NEURO plan. Note below how Ron has engaged in his lifestyle choices and activities, support intervention and why.
N-Nutrition*
Whole food, plant-based diet, low sugar, salt, and processed foods. Describe how Ron engaged with his choices and the planning and preparation of his shopping.
E-Exercise*
Active lifestyle – movement every hour, for example, walking around the garden, walking to his toilet, bathroom, kitchen.
U-Unwind*
Stress and fatigue management – meditation, weighted blanket, massage pad, yoga, mindful breathing exercises, massage, audio books.
R-Restore*
Note how Ron prepared for bed. Goal – 7-8 hours’ sleep per night. Note techniques used to improve sleep hygiene, e.g. promoting the same time to bed each night and same time to get up each morning.
O-Optimise*
Music, social interaction, Angel Cards, Church new activities, and learning
5. Nutrition

Refer to NEURO Plan. Ron has his meals prepared and cooked by his support staff due to his physical limitations and lack of interest, Detail what Ron has eaten.
Breakfast*
Lunch*
Dinner*
Water*
Other Fluids*
Other Foods*
6. Continence & Bowel Management*
Describe level of support required, prompts and if he has required assistance with hygiene.

Delete Yes or No as appropriate and complete boxes

Incontinence of urine? Incontinence of faeces? Loose / Hard Bowel movement amount? Small / Medium / Large
Comments
7. Cognitive Observations

Note difficulty with memory, insight into needs and risks, confusion, disorientation, and any other cognitive difficulties observed and strategies used to assist.
Memory*
Insight into needs and risks*
Confusion/disorientation*
8. Psychological and emotional needs*
Note difficulty with expressing distress, look for changes in breathing patterns,
body tension, fidgeting, repetitive vocalisation, crying, searching for staff or family members to seek comfort, facial expression (e.g. grimacing, wide eyes, clenching teeth etc) low mood, difficulty making informed decisions, lack of insight into his condition.
9. Communication*
Note any difficulties, relevance, has Ron been repetitive and anecdotal, (not necessarily a reliable account) has he reliably communicated his needs or required support?
10. Mobility Note*
Any difficulty to sit up safely, or standing and moving around, or observations of Ron tiring easily and becoming unsteady.
11. Skin Integrity*
Note assistance required and appearance of skin today. Note if reference to the body map required.
12. Diary
Ensure Ron is choosing how he wants to spend his day and briefly note an overview of how Ron spent his day, how he engaged, and support required. Include changes in Ron’s needs and/or usual behaviour or routine and action taken. Also include unusual or changed circumstances that may have affected Ron – highlight any deviations.
Morning*
Afternoon*
Evening*
13. Staff Contact with Ron’s family*
14. Note any staff or Client contact with Team Leader or Case Manager*
Include matters or concerns regarding Ron’s health and well-being or requests made for assistance over and above that agreed in the care plan.
15. Incidents/Accidents*
Brief description – Fill in form and email to TM/CM
Risks and action taken to minimise them*
16. Staff Contact with Primary Health/Social Care Services regarding Client and any appointments*
17. Night Care*
Note if Ron required assistance during the night, and detail the support given to assist him and why.
Any Other Feedback*

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Incontinence of urine?	Incontinence of faeces? Loose / Hard	Bowel movement amount? Small / Medium / Large