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Daily Record Form - S H - CM20
Daily Record Form – S H – CM20
Step
1
of
3
33%
Name of Support Worker
*
First
Last
Date of the session
*
DD slash MM slash YYYY
Session Start time
*
:
Hours
Minutes
Use 24hr clock
Session Finish time
*
:
Hours
Minutes
Use 24hr clock
Supporting at meal times
Did Sammy need any support with making her breakfast today?
Yes
No
Not Applicable – I was not there for breakfast time
If yes, then please give details
Did Sammy need any support with making her lunch today?
*
Yes
No
Not Applicable – I was not there for lunchtime
If yes, then please give details
Epilepsy and Seizure Monitoring
Did Sammy have any seizures the night before your session with her?
*
Yes
No
If yes, then please give more details
For example how long did the seizure last, what time did it happen, was Sammy taken to the doctors or hospital?
Did Sammy experience a seizure today?
*
Yes
No
If yes, then please score the severity of the seizure
0 – Low Level
1 – Moderate Level
2 – High Level
3 – Severe Level
If yes, then please give more details
For example how long did the seizure last, what time did it happen, was Sammy taken to the doctors or hospital?
Health
Was Sammy breathless at any point today?
*
Yes
No
If yes, then please describe what Sammy was doing at the time
Did Sammy experience a tremor today?
*
Yes
No
If yes, then please score the of the tremor
0 – Low Level
1 – Moderate Level
2 – High Level
3 – Severe Level
If a tremor did occur, please give specific detail. For example, how long did it last, how many times did it happen and when did it happen? Were there any triggers?
Fatigue
Did Sammy experience any episodes of fatigue today?
*
Yes
No
If yes then please score Sammy's fatigue levels
1 – Low Level of Fatigue
2 – Moderate Level of Fatigue
3 – High Level of Fatigue
4 – Maximum level of Fatigue
Please give details of times and duration when Sammy was fatigued
Balance
Has Sammy lost her balance today?
*
Yes
No
If yes, please give detail/what had caused her to lose her balance? Where was she at the time?
Mood and Anxiety
Please rate whether Sammy was anxious / stressed today on a scale of 0-4
*
0 – Not anxious at all
1 – Slightly anxious
2 – Moderately anxious
3 – Very anxious
4 – Extremely anxious
Please give detail of anything that may have triggered these feelings
Please rate whether Sammy was emotional today on a scale of 0-4
*
0 – Not at all emotional
1 – Slightly emotional
2 – Moderately emotional
3 – Very emotional
4 – Extremely emotional
Please give detail of anything that may have triggered these feelings
Engagement
Did Sammy show any reluctance to participate today?
*
Yes
No
If yes, then please give further detail
What was she reluctant to participate in and why
Please give detail of any achievements/progress made today. Did Sam participate in any new activities?
Did Sam need to pay for any items today, if so did she need assistance (with her purse or her card)?
General
Please give details of any general observations that you noticed today during your session
Do you have any safeguarding concerns?
*
Yes
No
If yes, then please give details
Is there anything further that Sammy's case manager needs to be aware of?
*
Yes
No
If yes, then please give details
