» Daily Record Form – Charlotte F

Name of Support Worker*

First

Last

Date of Support Session*

Session Start time*

:
HH

MM

Please use 24hr clock

Session End time*

:
HH

MM

Please use 24hr clock

Mood and Fatigue

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

2. Please rate Charlottes 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 Charlottes fatigue level and why?

3. How does Charlotte rate her fatigue today, on the same scale?*

4. Does Charlottes answer reflect your observation?

Activities

5. Has Charlotte independently used the diary as a guide today?*

Yes
No
N/a

Please comment if neccessary

6. Please describe how Charlotte has used the diary. E.g. as a reminder*

0 – Checking for a specific event
1 – Adding an event
2 – How often has Charlotte checked the diary
3 – What level of encouragement / support was required
4 – Were verbal or physical prompts given

Please comment if necessary

7. Has Charlotte followed the food plan?*

Yes
No
N/a

8. Please outline Charlottes day, describing activities and including information relating to food prep and eating.

9. What time did Charlotte get up?

10. Did Charlotte require assistance to wake boys?*

Yes
No
N/a

11. Was Charlotte involved in getting boys ready? Please describe including information relating to breakfast, getting dressed, getting bags ready

12. Did Charlotte accompany the boys to school?*

Yes
No
N/a

13. Did Charlotte take a morning nap?*

Yes
No
N/a

14. Did Charlotte indicate what time she wanted to nap until?*

Yes
No
N/a

15. Did Charlotte initiate a lunch plan? Please describe

16. Did Charlotte have a therapy session today?

Yes
No
N/a

17. Did Charlotte include SALT therapy in her social activities?

Yes
No
N/a

18. Did Charlotte plan any activities for the children?

Yes
No
N/a

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

20. Please describe any social or community-based activity that Charlotte took part in today e.g. meeting family, shopping, manicure etc,

21. Did Charlotte write a shopping list?

Yes
No
N/a

22. Did Charlotte accompany the children home from school?

Yes
No
N/a

23. Did Charlotte walk?

24. Please describe evening routine and activities, consider factors such as whether Charlotte independently initiated any activity, what prompts were given, level of support given.

Mobilty

25. How has the home environment impacted on Charlottes function today? Please consider space, spills, trips, clutter etc.

26. How has the outside environment impacted on Charlottes function today? Please consider, steps, carrying things, mobility etc.

27. Has Charlotte used any mobility aids today?

Correspondence and finances

28. Did Charlotte ask for any assistance to go through bills/letters/correspondence? Please describe.

29. Did Charlotte require support in working out costs and paying for items, or using her PIN? Please describe.

Childcare

30. Please describe level of input Charlotte received in caring for the children today.

31. Please describe the children’s bath time, including how much support was given.

32. Please describe the children’s bedtime including level of support given, please consider details such as story time.

33. Did you need to intervene in any incidents relating to management of the children’s behaviour? Please describe.

Memory and communication

34. Please describe Charlottes ability to communicate today. Consider any word finding difficulties and Charlottes ability to express herself.

Medication

35. Has Charlotte taken any medication today? Please detail level of supervision, time, reason, dosage.

36. Please comment on Charlottes skin, are there any open cuts, rubbing, friction marks or irritations?

Any Other Comments

37. If there is anything further you would like to add please comment here.