Daily Record Form – Harry D | Libertatem Healthcare

Username:
Client Name*
Name (s) of all Support Worker on shift today*
Date of Shift*
Date Format: DD slash MM slash YYYY

If you are undertaking night shifts, please remember to enter the correct date the shift started.
Shift Start Time*

: HH

MM
Shift End Time*

: HH

MM

Day time routine
Please give a general overview of what you did during your shift with Harry today.*
Include any appointments, whether you accessed the community with Harry, and provide details on how you got there, and where you went, as well as assistance Harry required.
Confirm a Lateral Flow test was done before your shift with a negative result.*
If you haven't done one today - include date of last LFT.
Describe the morning routine including what time Harry was given breakfast and when hygiene needs were attended to.
Was harry able to access his morning meds without assistance?*
- Yes
- No
If no, explain where assistance was needed.*
Are there any medications that may need reordering? If so, document whether you’ve told Jen or Harry.*
Has Harry been medically well today?*
- Yes
- No
Any complaints of pain, or any productive cough, for instance?
If No, please give details;*
Did Harry do any exercise, stretches or physio today?*
- Yes
- No
If No, Why not?*
If Yes, Give further details?*
Include what exercises were done. Include what support was needed from yourself.
Did Harry wear his hand splints or similar aids today?*
- Yes
- No
If Yes, Give further details?*

Night time Routine
What time did Harry choose to go to bed?*

: HH

MM
Did Harry wake you up / need any assistance during the night?*
- Yes
- No
If yes, give further details*
What time did Harry wake up in the morning?*

: HH

MM
Was Harry's night bag changed in accordance with the care plan instructions?*
- Yes
- No
If no, why?*

Personal Care
Did Harry require any assistance with a wash today?*
- Yes
- No
If yes, give further details.*
Were there any signs of redness today when doing a skin check on Harry?*
- Yes
- No
If so, what actions did you take-such as completing incident form/body map and updating Clinical Lead and Jen.*
Were barrier creams used on Harry?*
- Yes
- No
If so, where and when were these used.*
Did Harry attend to his own pressure area care needs or did staff assist? Please provide details below.*

Toileting & Bowel Care
Was Harry's catheter bag changed today?*
- Yes
- No
This should be done weekly. Generally on a Monday.
What was Harry's urine output during your shift today?*
Confirm you asked Harry’s permission and advice before emptying his catheter-or before any other intervention.*
- Yes
- No
.
Please mention if there were any concerns regarding volume of urine, any signs of UTI noted or any catheter blockages today. Include actions taken*
Signs of UTI noted include such as cloudy/foul smelling urine?
Did you carry out the bowel care routine during your shift?*
- Yes
- No
If no, why not?*
Was an output received and recorded on the Stool Chart?*
- Yes
- No
If yes, what time did the regime start?

: HH

MM
Regime finished at;

: HH

MM
Please mention if there were any concerns during bowel care during your shift.

Autonomic Dysreflexia
Did Harry show any signs of AD today?
- Yes
- No
If yes, please give full details including BP readings and actions taken. Include signs noted, and symptoms Harry complained of, as well as what the noxious stimulus could have been.

General
Were there any issues with missing, broken, or unsuitable equipment or facilities today?*
- Yes
- No
If yes, then please provide details
Any other observations/problems during your shift that you would like to report to the Care Coordinator, Clinical Lead or Case Manager?
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