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Home
About Us
Our Official Charity Partner
Meet the Team
Clients
Testimonials
Acquired or Traumatic Brain Injury
Spinal Injury
Other Medical Conditions
Live Vacancies
Register CV
Candidates
Apply online
Supporting Our Official Charity Partner
Subject Access Requests
Refer a Friend Scheme
Care Packages for Brain and Spinal injury
Contact Us
Submit a Daily Record
Daily Record - Ava P - Day Shift
Step 1 of 16
6%
Client Name
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Name of Support Worker(s) on shift today
*
Date of Shift
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Date Format: DD slash MM slash YYYY
Shift Start Time
*
:
HH
MM
Shift End Time
*
:
HH
MM
Morning Routine
Did you receive a handover before starting work?
Yes
No
When taking handover from the night staff (either LHG staff or Agency RN’s) -have you confirmed when AP went to the toilet during the night, as well as confirming amounts passed? Have you also confirmed medicines given, and taken a thorough handover. Please record any issues handed over below.
Any issues of concern reported via handover?
Record below-and include actions taken to resolve any issues
What time did Ava get up today?
*
Please confirm Ava's equipment has been checked to ensure it is in working order.
*
I confirm
I cannot confirm
Is Ava's equipment all in working order?
Yes
No
What actions have been taken to address any issues with Equipment?
Please describe Ava's hygiene routine:
including, transfers, whether she stood, or sat in the shower; whether creams were applied, was hair washed, and how much Ava was able to self-care? Include details about teeth brushing, and level of assistance that was required-as well as details of any fatigue during this activity.
Has Emily supported Ava in personal care?
if yes, please provide details:
Any issues with skin integrity noted?
Please describe any issues with skin integrity (such as wounds, eczema, pressure area care-please confirm that this has been recorded on a body map, and confirm that the Clinical Lead and mum have been updated if and as required.
Has Ava being weighed this morning?
*
it should be done on a Tuesday and Friday morning before breakfast/shower
Fluids & Nutrition
Please confirm Ava's diary charts been accurately filled in to reflect her dietary intake from her meals and snacks?
*
I confirm
I cannot confirm
Please confirm completed diary charts have been named and stored correctly to enable access to this information in the future?
I confirm
I cannot confirm
Please confirm Ava's fluid balance chart has been accurately updated-to include all drinks that she has consumed today
I confirm
I cannot confirm
Please confirm that the accurately completed diet and fluid summary sheets have been stored in the appropriate file on the desktop-and then organised further into year/month/date.
I confirm
I cannot confirm
Was Ava offered choice, and were there any issues around offering choice? Please provide details below. Describe the support required to enable Ava to make a decision
Did Ava help with meal preparation-including cleaning up and related tasks? Please provide further details below
Yes
No
Was Ava’s overall dietary intake sufficient today? If not-please provide brief summary explaining why this is the case. If so-also provide brief summary explaining your opinion
Was Ava’s overall fluid intake sufficient today?
*
Yes
No
If not-please provide brief summary explaining why this is the case. If so-also provide brief summary explaining your opinion
Was Ava able to help prepare her breakfast? Please detail below. Did Ava have any difficulties around making choices? If so-please, document below.
*
Yes
No
If yes, please provide details
Was Ava able to help with cleaning up the kitchen after breakfast? Please detail below.
What was Ava’s total fluid intake during your shift?
Please confirm that mum has been updated with accurate fluid intake and output totals
I confirm
I cannot confirm
If not able to update mum-please explain why below
Was Ava weighed today? If so-please record weight in Kg below. This is to be completed weekly at the same time and day each week.
Toileting
Did Ava request to use the toilet? What time? Time off the toilet?
If AP didn’t ask to use the toilet what made you think she needed the toilet? E.g. it has been 6 hours since she went. Or she displayed behaviours indicative of needing the toilet. Please describe what these behaviours were
Did Ava use the toilet for either bowels or bladder?
Please state if AP was incontinent of urine or bowels. Please state time and describe why this may have happened.
Did Ava require prompts / encouragement to use the toilet? Did she agree to use the toilet when prompted / encouraged?
Yes
No
Were the Stool chart and Fluid charts accurately completed and was this chart stored in the appropriate file on the desktop-and then organised further into year/month/date
Yes
No
Has Ava has difficulties with constipation during your shift? Consider amount of days since last bowel activity, and whether laxatives have been used. Also whether passing gas (flatus)-or if smearing/abdominal distension is noted
Therapies
Can you confirm the sofa has been returned to the correct place, medicines have been securely locked away and also confirm AP’s stim glove (and any other equipment you’ve used today) has been tidied away carefully?
Yes
No
What activities were offered and when. Did Ava choose the activities? Y/N If not why not? How long did Ava engage in the activity?
Has the Activities Recording Form been accurately completed? This should be dated correctly, and should have information about fatigue (before and after), choices, times to and from and whether this was spontaneous, or part of scheduled therapy programme
Who put A's KAFO's splint on and who assisted?
Did Ava try any new activities? Please detail below.
Confirm the Activities Recording Form been stored in bespoke folder? This may need to be referred to in the future.
I can confirm
I cannot confirm
Were any issues encountered with Ava's therapy sessions?
*
Yes
No
If yes, please provide details
Was fatigue, motivation or other behavioural concerns problematic?
What therapies and appointments Ava had in the day? Please provide brief summary, and confirm details accurately recorded on Activities Recording Form. Also confirm this form has been sorted correctly and can be easily accessed if needed.
Has there been any observations made during the physiotherapy exercises?
e.g AP complaining of left ankle pain, or AP very motivated today, or AP able to lift her right leg higher than normal today (these are just examples)
Has A completed any standing transfers that day? and if so which transfers they were and at what time.
if so, which transfers they were and at what time.
Please describe / list which physiotherapy exercises AP has completed today, including time completed, which exercises and number for repetitions:
*
Please detail why this was not undertaken
Were Ava’s physio exercises and interventions carried out as directed by physio?
*
Yes
No
If no, please provide details
Please record issues that meant physio programme could not be followed as directed
Were Ava's splints / spinal jacket applied an accordance with her therapists’ instructions?
Please detail times used, and limbs/types of splints used. Also record any issues, such as complaints of discomfort, pressure area issues
Please detail times used, and limbs/types of splints used. Also record any issues, such as complaints of discomfort, pressure area issues.
Were communication and other strategies followed in accordance with instructions from relevant therapists?
Yes
No
This helps to prevent perseverance and provides “scaffolding” to help with Ava's lack of executive function
Please document issues preventing this below.
*
Did Ava partake in any leisure/pleasure activities today?
If so-please describe below and confirm all detailed on activities chart.
Any barriers to Ava completing her physiotherapy exercises, wearing her KAFO splint, or completing standing transfers?
e.g fatigue, low mood, only one support worker on shift, no available time, etc
Have you cancelled any therapy sessions today?
if yes, what session and why?
Moving and Handling
Please state what postural change was carried out, the equipment used, the time, how long it took and how many staff were needed?
E.g. 7pm - Ava was transferred to the toilet using the rota stand with two staff.
Please describe if there were any issues experienced when moving and handling AP today
Menstruation
Please state the day Ava started her menstrual cycle? Please state how many days she has been menstruating?
Has Ava reported any symptoms? If so-please record this below.
Has Tranexaminc Acid been administered as directed in eMAR. If so-provide brief summary of effectiveness and reasons for administering this medication.
Please summarise any care delivered to meet Ava’s care needs whilst menstruating.
Behaviours, Mood and Insight
Was there any challenging or inappropriate behaviours during your shift?
Has an ABC chart been completed? This should include details such as time of ABC, potential trigger/antecedent behaviour, type of behaviour observed, length of time of incident, how this was resolved, any injuries, who was mainly at risk etc. If the ABC chart was not completed please state why?
Was Ava able to reflect on one positive experience or event from today?
Yes
No
What event was reflected upon and why did Ava feel the event was a positive experience.
Did Ava express any thoughts of self-harm, or actively engage in self-harming type behaviours?
Yes
No
If so-please provide further details and confirm ABC chart completed. Did Ava have issues with low mood today? If so-please provide further details, such as a description of low mood noted, whether any escalation to mum or Clinicians was needed, whether this mood issue lasted the whole shift, or part of the day
Please rate Ava's overall mood today from 1-5
1
2
3
4
5
(1 is low, and 5 is high/good).
Has Ava been offered opportunities to rest during the day?
Yes
No
Please describe when and also describe how this rest period was facilitated by staff on duty.
How long did Ava rest for? Please state if Ava slept during her rest period.
Did the rest periods offered have a positive effect on Ava’s overall wellbeing? Please provide further information to evidence your opinion.
Please state if Ava did not have the opportunity to rest today and why.
E.g. Ava was at a hospital appointment. However when she returned home a rest break was facilitated at 4pm for 45 mins.
Seizure Activity
Did Ava present with any behaviours indicative of od possible seizure activity today?
Please describe any signs or symptoms, e.g. Ava had a fixed stare and was unresponsive for 1 minute
If there was seizure activity, has this been thoroughly documented using seizure chart?
Yes
No
If there was seizure activity-were any interventions needed to help Ava?
Yes
No
Therapy Appointments (Including her Tutor)
What therapy appointments took place today, time and duration. Please describe what happened in each therapy session and any feedback that the team need to be aware of.
Medical Emergencies
Was Ava unwell requiring medical intervention?
Please describe, who was contacted and the intervention carried out?
Has Ava asked to attend any events, or take part in any activities in the community or in the home today?
Yes
No
If yes, please provide details:
Has Ava attempted to make any purchases today (either using phone, or in person).
Yes
No
If yes, provide details, such as if and how she was redirected, what she was interested in, costs etc.
Pain / Spasticity
Did Ava experience any difficulties with pain / spasticity during your shift?
Yes
No
Please detail when Ava had pain, and where this pain was.
Consider also how long the pain lasted, and what strategies were used to minimise discomfort. Rate pain from 1-5-with 1 being low.
Did any of these difficulties cause Ava to have to reschedule plans or activities?
Yes
No
Skin Integrity
Are Ava's old PEG and Tracheostomy wound sites are both intact?
Yes
No
Are there any new wound sites?
*
Yes
No
Please provide additional details
*
Please state where and why? Please state if Ava has been picking at her wound sites. Confirm that Clinical Lead has been updated and that body map has been completed
Has Ava been encouraged to change her position every two to three hours during the day? Please record when these position changes took place.
Meds Administration
Have Ava's medications been administered as prescribed and recorded on the eMAR chart?
*
Yes
No
Did Ava take all her medications as prescribed?
Yes
No
If not-please detail issues below, and consider whether incident form is required.
*
Were there any difficulties with the management / re-ordering of Ava's medications?
Yes
No
Has Ava had any changes to her medications?
Yes
No
Were any PRN medications administered today?
Please state which medication, the time administered and why. E.g. in response to pain. If so-has this been recorded on eMAR, and has detailed carer’s note been entered describing why, where and when this medication was administered-and whether it was effective.
Did any medical appointments took place today, time and duration. Please provide feedback from the appointment.
Safety
Are there any issues that require urgent attention of management?
Yes
No
Can you confirm that you have checked and answered (if required) team emails?
I confirm
I connot confirm
Have you given a detailed handover to staff taking over from you in the evening?
*
Please detail any major issues you are handing over.
Covid
Were there any Covid related concerns?
*
Yes
No
Potential contact with a positive case, or perhaps symptoms such as cough or high temperature?
Have staff on duty completed LFT that is required before each shift with AP? Have all results been uploaded, and actions appropriate to results taken?
Yes
No
Please provide additional information
*
Were there any other Covid related concerns? If so-provide brief summary and confirm detailed incident form has been completed and submitted.
Can you confirm that you have checked and answered (if required) team emails?
*
Yes
No
Domestic
Have you completed any house hold chores today?
Yes
No
If no, please provide the reason why:
Can you please confirm that you have completed Regular/Daily Checklist - Ava P for completed domestic chores?
*
Yes
No
If no, why not?
Can you please confirm that you had AP teams mobile all the time and all the calls/messages have been looked at and answered?
*
Yes
No
If no, why not?
Feedback
Please record a brief summary of the shift:
Safeguarding & Additional Feedback
Is there anything that either Libertatem Healthcare or Ava's Case Manager or Libertatem Healthcare need to be made aware of?
Yes
No
Please provide further details
*
Do you have any safeguarding concerns?
*
Yes
No
Please provide further details
*
Signature
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