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Daily Record Form - H M
Daily Record Form – H M CLOSED
Name of Rehab Assistant
*
First
Last
Date of Rehab session
*
DD slash MM slash YYYY
Session Start Time
*
:
Hours
Minutes
Please use 24hr clock
Session End Time
*
:
Hours
Minutes
Please use 24hr clock
Subjective (S) This is information from the client’s perspective. Information the client reports, directly to you. Use these questions to help you describe the session:
When and where did this happen?
Why were you there?
Who else was there?
What happened?
What did you do?
What did other people do?
What was the result of this situation?
Objective (O) This is the information collected through observations. How you see it from your objective observation. Think about how you felt using these questions to help you record your observations of the session:
What did you feel before this situation took place?
What did you feel while this situation took place?
What do you think other people felt during this situation?
What did you feel after the situation?
What do you think about the situation now?
What do you think other people feel about the situation now?
Explain here what happened during the session and then use these bullet points to help you be reflective about the session in relation to these areas:
• Problem solving
• Perseveration
• Planning
• Monitoring
• Disinhibition
• Memory
• Emotional liability
• Anxiety
• Risk
Assessment (A) This is the conclusions taken from the information collected. The basis of your rationale. What went well and what didn’t go so well. Also write what you contributed to the situation. Think about these questions to support reflective thought on your conclusions from your session:
How could this have been a more positive experience for everyone involved?
If you were faced with the same situation again, what would you do differently?
What skills do you need to develop, so that you can handle this type of situation better.
Plan (P) How you're going to get to your goals. Defines the proposed intervention/what you're going to do/or that you need to refer back to the team for further plan or confirmation of it.
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