Daily Record Form – Emma J | Libertatem Healthcare

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
Shift End Time*

: HH

MM
Brief Overview of today (what, when, how)*
How much encouragement are you giving to Emma?
How much and where you encouraged Emma
Has Emma at any point declined your encouragement?*
- Yes
- No
If yes, please provide more details

Motivation and Initiation
Were Prompts and Encouragements needed to motivate your client today?*
- Yes
- No
Did your client respond to these prompts?*
- Yes
- No
If you answered yes to either of the two previous questions then please give details*

Psychological and Emotional
Were there any instances of mood disturbance, anxiety or stress observed today?*
- Yes
- No
Were these instances predicted (i.e. covered in the Care Plan)?*
- Yes
- No
If you answered yes to the 2 previous questions, please give a brief description of the instances that occurred and the actions that you took.*

Accessing the Community
Was your client involved in any activities in the community today?*
- Yes
- No
Did they require your support or intervention when out and about?*
- Yes
- No
Did your client put themselves at risk out in the community?*
- Yes
- No
If you answered yes any of the previous 3 questions, then please give more details*
Can you confirm that Emma's car is in good order and there are no damager to the car?
- Yes
- No
including flat tire, expiring MOT ect
If no, please provide more details:

Behaviour
Did your client display and impulsive or inappropriate behaviour today?*
- Yes
- No
If you answered yes, then please give details

Pain
Did your client experience any episodes of pain during their planned activities today?*
- Yes
- No
If you answered yes to the previous question, then please give details

Nutrition and Fluids
Please give an overview of your clients meals today*
Please select an approximation of your clients fluid intake today*
- 0-1 Litre
- 1-2 Litres
- 2-3 Litres
- 3+ Litres

Medication
Did your client take their medication as outlined in their care plan today?*
- Yes
- No
- No medication required
Did your client have any changes to their medication or is there any planned?*
- Yes
- No
Do you have any safeguarding concerns?*
- Yes
- No
If you answered yes to the question above, please give details
Please give an overview of any personal care delivered today that was not covered in the care plan
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