Daily Record Form – John S Evening Shift

User's Email
Username:
Client Name*
Name of 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
Brief Overview of the evening shift (what, when, how)*

Goal Progress
Please list the goals you have worked on with John during your shift
For each goal listed above, please provide a detailed description of the actions achieved or completed

Managing Fatigue
Did John's level of fatigue impact on his participation in activities during shift?*
- Yes
- No
If yes, then please describe how this presented and affected John*
Was John able to independently recognize signs of fatigue this evening*
- Yes
- No

Mobility
Did you have any concerns regarding John's mobility during your shift this evening?*
Did John require and hands on assistance or contact guarding to maintain his safety/balance this evening?*
- Yes
- No
If yes, please provide details*
Were there any falls/near falls that required your intervention this evening?*
Please give a summary of how John’s mobility is during your shift.*

Medication
Did you administer John's medication this evening?*
- Yes
- No
If you answered no, did you split the evening and night medication into 2 x pots and leave them on johns table with a drink for John to self-administer and set a timer/ alarm on his phone?*
Communication
Was John able to communicate his needs during your evening shift?*
- Yes
- No
Have there been any healthcare professionals visit or calls today?
Did John say anything inappropriate on the evening shift?*
- Yes
- No
If so, what was said?*

Diet
What meals were covered during your Shift ( please keep the CRTL button down to select multiple)*
- Dinner
- Snacks
Please details below what John ate during the meals
Please give an overview on how they chose their meals*
Please give an overview of Johns fluid input during your shift.*
Were there any episodes of choking? If so please describe when and how this was resolved.*

Finances
What expenses have been used this evening?*
General
What time did John go to bed this evening?*
Any safeguarding concerns or important information to be reported to Libertatem or the case manager?*
Signature Pad

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