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Daily Record Form - S RSR CM64 & 65
Daily Record Form – S RSR CM64 & 65
Step
1
of
2
50%
Name of Support Worker
*
First
Last
Support Worker No.2
First
Last
Date of Support Session
*
MM slash DD slash YYYY
Session Start time
*
:
Hours
Minutes
Please use 24hr clock
Session End time
*
:
Hours
Minutes
Please use 24hr clock
1. On your arrival was the property adequately heated?
*
Yes
No
2. How was his mood on your arrival?
*
3. Did he require immediate attention with anything?
*
Yes
No
Comments
3.a. Did he comment on how he had slept? Did he mention whether he was tired? Did he appear tired?"
4. What position was he in on arrival?
5. Did he require repositioning?
*
Yes
No
If yes, please explain why and how this was achieved.
5.a. Did district nurses visit?" Y/N? If Y what time? and what tasks did they carry out?
6. Did you provide any personal care?
*
Yes
No
If so note whether bowels opened, catheter patent, draining and emptied. Diet and fluid intake. Washing / personal hygiene. Dressing and undressing.
7. Any other tasks?
8. Did he report any pain/altered sensation / discomfort?
*
Yes
No
If yes, please comment
9. Was there any evidence of redness over pressure areas?
*
Yes
No
If yes, please comment
10. Did he co-operate with activities?
*
Yes
No
Comments
11. Did you encounter any difficulties in carrying out tasks?
*
Yes
No
Comments
12. Was the equipment you used in good order?
*
Yes
No
Comments
13. What activities did he do today?
14. Did he do any community activities?
*
Yes
No
If trip out please comment on where, when, with whom and for what purpose. What time did he depart and then return home?
*
Comment if ‘Yes’. If No write ‘N/a’
15. How much time did he spend in his powered wheelchair?
16. Did you notice any changes to his skin condition after sitting out in his wheelchair? Were there any new skin marks?
If Yes please explain further / comment.
*
Comment if ‘Yes’. If No write ‘N/a’
16a. Was he visited by family members, friends or professionals?
*
Yes
No
If yes, by whom?
17. Did you have any issues or concerns?
*
Yes
No
Comments
17a. Was his vehicle used today?
*
Yes
No
17b. Did you identify any issues / problems with the vehicle?
*
17c. Do you have any suggestions regarding the vehicle
*
Yes
No
17d. Did you need to refuel the vehicle?
*
Yes
No
How much fuel was purchased?
*
Comment if ‘Yes’. If No write ‘N/a’
Physiotherapy exercises:
18. Which exercises did you complete (please tick)?
*
Exercise 1 – Shoulder mobilisations
Exercise 2 – Mobilisation of sh abductors
Exercise 3 – Elbow movements
Exercise 4 – Mobilisation of hands
Exercise 5 – Accessory movements of hand
Exercise 6 – Massage to remove swelling in hand
Exercise 7 – TA stretches
Exercise 8 – Active assisted movement of legs
Exercise 9 – Resisted strengthening leg exercises
Exercise 10 – Resisted arm exercises
Exercise 11 – Trunk stretches
All Exercises carried out
No Exercises were carried out
If 'no exercises', why did he not carry out exercises?"
Any other comments?
Physiotherapy assessment:
19. Please describe outcome of exercises. (a) Did tone and stiffness reduce (b). Was he able to actively work with you following the mobilisations and stretches (c). Were there any problems (d). Did you note any changes today (e). Any other comments/concerns
*
20. Were you required to handle any money?
*
Yes
No
If yes, why were you required to handle money and how much?
21. How was RSR's mood during the shift? Did you have any concerns about his memory / recall?
*
22. Are there any messages for the following or subsequent shifts?
*
Untitled
First Choice
Second Choice
Third Choice
