Daily Record Form – Ava P – Night Shift

Client Name*
First
Name of Support Worker(s) on Shift*
Date of the shift*
Date Format: DD slash MM slash YYYY

Please remember to enter the correct date the shift started.
Shift Start Time*

: HH

MM
Shift End Time*

: HH

MM

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Seizure Activity
Was any seizure activity observed overnight?*
- Yes
- No
Please confirm that this has been fully recorded on seizure documentation provided? please document any further actions you may have been required to take, such as summoning mum to help, or calling for outside assistance in the form of 111/999.*
Were any hygiene interventions required for issues such as incontinence, or similar?*
- Yes
- No
If so, please detail below
How would you rate Ava's overall quality of sleep during the shift from 1-5?*
1 being poor & 5 would be excellent.
Record any other issues or concerns you may have encountered?*
Please record a brief summary of the shift.*
Is there anything you would like to raise to Ava's Case Manager or Libertatem Healthcare?*
- Yes
- No
Please give further details*
Do you have any safeguarding concerns?*
- Yes
- No
Please give further details*
Signature*

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