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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 Form - NM Day Shift
Step 1 of 11
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User's Email
Username:
Client Name
*
Name (s) of Support Workers on shift today
*
Today's Date
*
Date Format: DD slash MM slash YYYY
Shift Start Time
*
:
HH
MM
AM
PM
Shift End Time
*
:
HH
MM
AM
PM
Skin
A full body check should be carried out by the support worker during the morning hygiene programme to observe NM’s skin for issues such as skin breaks/dry patches/ irritation, scratches and non-blanching areas? Confirm that this took place and if applicable provide a summary of any issues identified and if applicable recorded on a body map. Write n/a if you were not responsible for this task during the morning double up.
Confirm NM (during the morning hygiene programme) was assisted to apply Cerave moisturising face cream to the face and Cerave body moisturiser to his body, including arms, chest, torso, legs, and feet. Also confirm that the support worker applied Cerave body moisturiser to NM’s back. Please write n/a if you were not responsible for this task.
Confirm that NM’s feet were thoroughly dried, checked for signs of athlete’s foot and daktarin spray was applied if necessary. Write n/a if you were not responsible for this task.
Did staff use all opportunities presented during the day to observe NM’s skin for issues such as dry patches (on forehead or cheeks) due to eczema, skin breaks (especially in corners of mouth), potential pressure sores and similar concerns as described in the care plan?
Yes
No
If yes, summarise any issues noted, and record whether Cerave face cream, Cerave moisturising body cream, Vaseline or Sudocrem was applied and whether the body map has been updated.
Hygiene
Were you responsible for NM morning hygiene programme?
Yes
No
In the morning, one staff member assists with NM’s hygiene programme while another staff member sets up the bathroom and bedroom to enable NM to initiate and carry out as many tasks as independently as possible during the morning hygiene programme.
*
Please confirm that the programme set by the occupational therapist was followed and the chart completed?
Yes
No
Please confirm that you supported NM to attend to his hygiene needs, including showering, oral hygiene, shaving and hair combing?
Yes
No
Please provide brief details below
Please comment on issues such as levels of NM’s independence, prompting required (especially during teeth brushing and shaving to prevent redness and soreness due to perseveration) and motivation
If responsible for setting up bathroom and bedroom confirm the set up was completed and both rooms were left tidy and hygienically clean, with bedding, towels, flannels, and clothing brought downstairs for washing when required. Record n/a if you were not responsible for these tasks.
Yes
No
N/A
Please confirm the bed remote, bed rails, handles and light switches were wiped with antibacterial wipes. Record n/a if you were not responsible for this task
Yes
No
N/A
Please confirm that NM’s 2 wheeled frame (Zimmer) was wiped with antibacterial wipes after the morning hygiene programme.
Yes
No
N/A
Please confirm hands were washed after going to the toilet and before meals?
Yes
No
Please comment if initiated by NM or if support/prompting was needed.
Continence
NM’s continence nurse and OT have designed a toileting programme to encourage approximately 2 hourly toileting trips into his day. Was this followed?
Yes
No
Please comment on whether NM initiated toileting or whether prompts/gentle guidance were required.
What times did NM subsequently visit the toilet to pass urine? Record times, colour and use the following code to provide further details (** = successful urine; * = unsuccessful; I = initiated; W = Wet). Please also detail any incidents of incontinence of urine and possible reasons for this (e.g. timing, overstimulated, anxiety).
Did NM open his bowels today?
Yes
No
If yes, record time and result, and refer to Bristol Stool Chart to categorise any output.
Has the toileting chart been completed?
Yes
No
Mobility
Please confirm the insole was present and positioned correctly and checked for signs of wear during morning hygiene set up. Please state n/a if you were not responsible for this task.
Yes
No
N/A
NM has a moulded insole that is placed in his left shoe, (there is also one in his outdoor shoe).
NM always wears his handling belt throughout the day, with the support of one when standing unaided (without holding on to for example a grab bar, worktop etc) and always when mobilising. Confirm this happened throughout the day and any times when he attempted to mobilise unaided.
Please confirm specific occupational therapy guidelines were followed.
Yes
No
Confirm Occupational Therapy guidelines were followed throughout the day with specific prompts and sequencing during transfer (sit to stand or stand to sit) and mobilising within the house.
Please comment on mobility and support given?
Comment on mobility during daily walks outside (in the garden, newspaper walk or walk in the village)
Please include any issues relating to balance, muscle tightness or weakness especially in the left calf, pick up of left foot, size of steps, posture, and speed of movement, in addition to any prompts or interventions required.
Please comment on mobility throughout the day when mobilising within the house (e.g. making lunch, cup of tea, laying table for dinner, using the stairs) and level of support required
Medication
Was all medication listed on the E Mar given as prescribed?
Yes
No
Please confirm what time the medication was administered?
:
HH
MM
AM
PM
Was any PRN medication required?
Yes
No
Please provide further details?
Did you check there were any signs of wheeziness due to exercise or pollen levels or any hay fever symptoms?
Yes
No
If hay fever symptoms present, did you discuss with NM’s wife and then proceed with PRN medication such as salbutamol inhaler for wheeziness or Beclomethasone nasal spray for hay fever?
Yes
No
N/A
If yes, please give details.
Blood Pressure
Please record blood pressure readings below, with the times taken. If applicable, comment on any recordings close to NM’s baseline readings of 105/69/69 and possible reasons for this and confirm after any abnormal readings the blood pressure was retaken and where necessary reported to NM’s wife for potential escalation.
NM suffers from low blood pressure and twice daily recordings have been requested by the cardiologist. It is important that NM mobilises at regular intervals throughout the day with regular fluid intake at set times. He also requires periods of rest with legs elevated.
Please record symptoms such as dizziness, especially when NM stands (due to postural hypotension) and lethargy can also be recorded here.
Clinical Observations/ Changes
Please record brief details and comment on any interventions required. This may include times when NM appears unwell, unsteady on feet, disorientated, or perseverates – engages in an activity for too long.
Nutrition and fluids
NM has eating and drinking /safe swallowing guidelines in place set by the SALT professional to prevent episodes of choking. These guidelines include encourage NM to sit upright, cut up, chew, and swallow his food slowly, taking small mouthfuls. Please confirm these were always followed during all meals.
Yes
No
One member of staff must always remain sitting at the table with NM whilst eating and drinking and be closely observed, with appropriate prompts where necessary, due to the risk of choking and burning self (if food too hot). Please confirm this happened.
Yes
No
If no, why not?
NM’s professionals have advised on softening foods and preparing his diet in a manner that helps to reduce the risk of choking. Was this advice followed?
Yes
No
If no, why not?
NM normally has breakfast after having his hygiene needs met. Confirm this happened?
Yes
No
If no, why not?
Please provide summary of breakfast intake.
NM has guidelines in place designed by his OT to enable NM to help with preparation of lunch. Were these followed?
Yes
No
What did NM help prepare for lunch?
Were there any episodes of choking or vomiting noted throughout the day?
Yes
No
If yes, please record below and include details of what happened, when and how this was resolved.
Did NM drink enough fluids today? Please provide summary of fluid intake, including times, types of fluids and estimates of volumes.
Any further issues relating to NM’s diet and fluid intake?
Yes
No
If yes, please record details.
Activities
Please list all activities undertaken during the day, with times and confirm the timetable was followed.
NM has a structured timetable to aid his rehabilitation with a programme of activities, which are both physically and intellectually stimulating, (balanced with periods of supported rest).
Therapy Sessions
When accessing the community NM needs to be assisted by 2 persons with one person always using the handling belt with NM. Did this happen?
Yes
No
If no, why not?
Which therapy sessions did NM attended today.
Physiotherapy
Hydrotherapy
Gym
Provide details of any therapy sessions attended today.
Please comment on specific exercises and any improvements with balance, posture, core strength, muscle strength, range of movement and flexibility. Please comment on any difficulties encountered with specific exercises and possible reasons for this, paying particular attention to NM’s left side with muscle weakness, increased muscle tone and muscle tightness.
Community Visits with Occupational Therapist/ Speech and Language therapist
Did NM participate in any occupational therapy or speech and language therapy led community visits today?
Yes
No
If yes, please state the aims of the visit and to what extent these were achieved.
Physiotherapy
Early morning physiotherapy programme – stretches.
Please confirm the programme has been followed and support was given to facilitate the movements in a smooth and controlled way, and within a comfortable range of movement, without pain or excessive effort If you were not the person supporting NM with this task, please state n/a
Yes
No
N/A
NM’s physiotherapist has a prescribed early morning physiotherapy exercise programme to mobilise stiff joints, to provide a gentle stretch with movement for tight muscles and to prepare the body for functional tasks such as rolling, transfers, personal care, and walking.
If no, why not?
Provide details/times of exercises NM completed.
Consider adding details about range of movement of the stretches in the upper and lower limbs on both the left and right side, muscle strength, posture, core strength and any difficulties encountered with the stretches (please indicate the specific exercise this related to).
Calf stretches.
Please state times and the calf stretch exercises that you supported NM with throughout the day
The consultant physician in Neurorehabilitation at NGH, along with the neurophysiologist has advised the importance of the calf stretches to limit the tension in NM’s left calf and extend the range of movement.
Home Exercise Programme
Did NM (with support) complete his home exercise programme today?
Yes
No
NM has a 45 to 50 minutes home exercise programme, devised by the physiotherapist, to meet NM’s physiotherapy goals to be undertaken on non- therapy days.
If no, why not?
If yes, please comment on individual exercises and how well NM carried out these exercises, paying particular attention to static and dynamic balance, core strength, range of movement (in both upper and lower limbs), muscle strength, core stability, postural stability, exercise tolerance and overall fitness. Please include any physical difficulties encountered with particular exercises and possible reasons for this (this may include NM’s left side muscle weakness, increased muscle tone and muscle tightness).
Communication
Communication is a key part in supporting NM and aiding him to develop his communication skills. He should be encouraged to engage in conversation at an appropriate adult level, without being patronising and talking over NM as if he wasn’t present.
Did NM participate in a therapy session with the Speech and Language therapist (SaLT) today?
Yes
No
If yes, please state any discussions of interest, where NM was fully engaged in the discussion. Please give any incidences, where NM became disengaged and possible reasons for this.
If no, why not?
Did NM participate in any mini SaLT sessions today
Yes
No
If no, why not?
If yes, please give brief details of this.
What quality informal interactions took place today, where NM’s contribution was more than 50%? Please give brief details of where this took place and the content of the conversation.
Did NM complete his plan of the day?
Yes
No
After breakfast, NM should complete his plan of the day, following the structured format from the SaLT. He completes his daily planner using his diary, IPad for the weather and staff rota, which all provide a reference point for his day and aids with orientation.
If no, why not?
Activities of Daily Living (Occupational therapy)
Did the Occupational Therapist visit today for a therapy session in the home to support NM in specific activities of daily living?
Yes
No
If so, please give brief details.
Medical/healthcare appointments or visits
Did NM attend any medical or hospital appointments today or was he visited by any healthcare professionals?
Yes
No
If yes, please detail below.
Behaviour
At times, NM will become agitated and shout out or exhibit other behaviours that are a result of cognitive difficulties associated with his ABI. This includes impulsively pushing back his chair or attempting to get out of his recliner unaided, without warning. Please provide a brief summary of any incidents noted – if any (include information such as any possible antecedents, whether redirection, distraction, verbal guidance was required to reassure or stop the behaviour and confirm whether these incidents have been documented on the OAS-MNR and the SASBA recording sheets provided by NM’s neuropsychologist.
Psychological & Emotional
As a result of the ABI NM can be disorientated and show anxiety or low mood. Please record any times during the day where NM appeared anxious or low in mood and possible reasons for this.
Safety
Was all equipment including handling belt, shower chair, high low profile bed, two wheel (Zimmer) frame given a visual check to ensure no obvious issues or faults during the morning set up? Please state n/a if you were not responsible for this task.
Yes
No
N/A
If no, why not?
Where NM is required to walk longer distances or for hospital or medical appointments a wheelchair may be required.
Yes
No
If yes, please provide more details.
Was a check made before using the wheelchair to ensure no obvious issues or faults? Write n/a if the wheelchair was not required.
Yes
No
N/A
As NM is at a high risk of falls and due to his impulsive behaviour, with lack of insight into his disability, he requires constant and uninterrupted supervision using direct visual observation during the day. During brief periods when the member of staff needs to leave the room, the monitor provided needs to be used. Please confirm this uninterrupted supervision took place.
Yes
No
If no, why not?
When NM mobilises during the day, he needs to be always supported with the handling belt. Please confirm this took place.
Yes
No
If no, why not?
When NM eats, he often tries to leave the table abruptly by pushing back his chair and standing up. This increases the risk of falls. Please confirm you supported as needed to stop this impulsive behaviour.
Yes
No
Please comment on any episodes of unpredictable behaviour where NM tried to get out of his riser/recliner unaided.
Were any safeguarding concerns noted today, and/or any incidents need investigating?
Yes
No
If yes, please give details?
Summary
Please provide any additional information not covered above, including any issues encountered and confirm a handover has taken place with the oncoming shift.
Yes
No
If yes, please give details.
Is there anything else that either Libertatem, NM wife, NM's Case Manager need to be aware of?
Yes
No
If yes, please give details?
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