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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
Step 1 of 9
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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
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:
HH
MM
Handover and checks
Did you receive a handover before starting work?
Yes
No
If not, why not?
Any issues of concern reported via handover?
Record below-and include actions taken to resolve any issues
Morning Hygiene
What time did Stella choose to have her hygiene needs met?
*
Was Stella showered today, or did she have a bed bath?
Conform Stella’s dentures have been cleaned in accordance with instructions in care plan, and confirm similar care has been delivered to her oral cavity.
*
Yes
No
Was Stella's skin checked for issues such as non-blanching or broken areas?
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 an incident form been completed
Provide information below if this is the case.
Have there been any signs of a Urinary Tract Infection-such as cloudy/strong smelling urine? And if so-what actions did you take?
Was Stella involved in choosing her own clothing today?
Was Stella asked if she wanted to make up or jewellery today? If so-please document below.
Was Stella’s knee wound dressing intact? If any intervention was required-please record details below.
If applicable, did the District Nurse visit to change Stella’s wound dressing on her knee?
This happens 2-3 times weekly.
Was any advice around wound care given by healthcare professional visiting? If so-please record below and confirm Clinical Lead made aware.
Bowel and Urine
What time did you begin Stella's bowel care routine?
Confirm that suppository has been administered as instructed on medicines administration record.
Yes
No
Did Stella require bowel stimulations to encourage bowel activity?
Yes
No
Did you confirm whether there was stool by carrying out a PR exam prior to stimulation.
Yes
No
Describe any bowel output with reference to Bristol Stool chart. Use egg cups to estimate volumes passed.
Did you change Stella’s catheter bag today?
Yes
No
If not, why not?
Confirm that catheter care has been delivered as instructed in the care plan.
If applicable, did the District Nurse visit to change Stella’s catheter?
This generally happens once a month, unless blockages or other issues are noted.
Has all urine output been recorded on Fluid chart.
If not. why not?
Breathing
Did Stella have coughing episodes today? Document when this happened, as well as any actions taken to resolve or reassure Stella.
Did Stella have any issues with shortness of breath? If so, when.
Please document help given, such as sitting up, reassurance, or use of nebuliser
Eating and Drinking
Was Stella observed at all times when eating or drinking?
This is needed to ensure she is at reduced risk of aspiration.
What did Stella eat today? Please record contents of meals, as well as times served and amounts eaten.
Was Stella involved in choosing what she wanted to eat?
Yes
No
If not, why not
Confirm food was pureed to a level 4 consistency and document any other assistance Stella needed to eat this meal.
Yes
No
Confirm Stella was sat upright, was constantly supervised and was alert when eating.
What did Stella drink today?
Confirm she was alert and upright when taking fluids.
Confirm fluid chart has been accurately updated to reflect fluid intake and output.
Please document any other assistance Stella needed to drink fluids during the day.
Activities and Therapy
Did Stella access the community today? Please record details, as well as assistance needed.
Did staff drive her wheelchair accessible van? Please record when and where to, as well as who went on the journey, and purpose of journey
Did Stella have a rest or nap during the day? If she did, can you please confirm the times that this took place, and also record whether she rested in her bed or in her chair.
Did you help Stella with any stretching or mobility type exercises today? If so, please record details such as type of exercise, limbs or body area involved-and when completed/how long taken.
Was Stella visited by family members? If so-please record times, as well as who the visitor was.
Was Stella visited by healthcare professionals, or by anyone else other than family members? If so, please record who this was, as well as purpose and length of visit. Add any further information you feel may be relevant.
Did Stella attend any virtual or over the phone appointments? Please detail below.
Describe any activities Stella took part in today
For instance, she enjoys Arts and Crafts, and staff may spend time helping her engage with this form of activity.
Cleaning
Did staff complete housework during the day?
Yes
No
Have all daily cleaning chores been completed? By whom?( Please provide initials)
Washing of sheets, towels and pillow cases and clothing
Ironing
Stock check and daughter or Libertatem informed of anything that is running low, reorder as directed.
Cleaning of all surfaces in Stella’s bedroom
Sweep floor or hoover floors where carpets are in use
Mop floors as appropriate
Clean bathrooms and mop floors
Kitchen surfaces cleaned after every use
All pots and pans washed and dried and tidied away
Bins emptied from house bins into the household waste bin which are by the back door
Tidy Live in carer room stayed, to change all the bedding and towel and to clean the room, hard surfaces and hoover.
Washed bed linen from live staff bedroom
Please document if you completed any other housework not listed above , how long this took-as well as specific tasks completed
If unable to complete any pre-agreed household tasks-please record and document reasons below.
Medication
Were all medicines administered as prescribed?
Yes
No
Have you completed a medication stock check on the team drive?
*
Yes
No
If stock check completed, Have you notified Clinical Lead?
If any problems or issues were encountered, please detail below.
This could be information about PRN medicines requirements, or even stock issues.
Did any Healthcare professionals visit today? If so, please provide times and details such as job titles below.
Did Stella take all her medications as prescribed?
Yes
No
If not-please detail issues below, and consider whether incident form is required.
*
Has Stella 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.
Has a daily medication audit been done ?
Yes
No
Has any required meds been ordered from GP ?
Handover
Have you given a detailed handover to staff taking over from you in the evening?
*
Please detail any major issues you are handing over.
Have you returned all keys and ensured Stella is safe and secure before leaving?
Safeguarding & Additional Feedback
Were any monthly regular tasks, such as ordering of PPE/repeat medicines or pad stocks completed today?
Yes
No
If yes , provide further information and confirm any outstanding tasks still needing to be done?
Is there anything that either Libertatem Healthcare need to be 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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