BASELINE FOR DAILY JOURNAL

NAME: MONTH : YEAR: ______

TO BE UPDATED BY HOUSE & DAY PROGRAM TEAM MEMBERS AS SIGNIFCANT CHANGES ARE NOTED, AND TO BE REVIEWED BY BOTH TEAMS EVERY 3 MONTHS

FOCUS AREA / HIGHLIGHT ALL STATEMENTS IDENTIFYING
THE ‘USUAL’ EXPECTATION
SLEEP / FATIGUE
HAS A SUPPORT PLAN / GENERALLY SLEEPS THROUGHOUT THE NIGHT / NO CONCERNS / 7-9 HOURS OF SLEEP REGULARLY
USUALLY UP TO TOILET ONCE IN THE NIGHT / OCCASIONAL DISRUPTION / APPEARS RESTED
QUESTIONABLE / SLEEPS POORLY / WAKES EARLY / NAPS OCCASIONALLY / APPEARS TIRED IN THE DAY
HAS DIFFICULTY FALLING ASLEEP / WAKES OFTEN / REQUIRES DAILY NAP/ SLEEPING PILL/ NIGHT CARE
COMMENTS:
APPETITE & WEIGHT
HAS A NUTRITION CARE PLAN / GOOD APPETITE / ENJOYS FOOD / NO WEIGHT ISSUES / NO DIETARY CONCERNS
FAIR APPETITE / DOES NOT SEEM TO ENJOY FOOD / APPETITE IS AFFECTED WHEN EMOTIONAL
POOR APPETITE / REFUSES FOOD OFTEN / REQUIRES SIGNIFICANT SUPPORT TO EAT WELL
SIGNIFICANT NUTRITION RELATED CONCERNS / REQUIRES 1:1 SUPPORT TO EAT / WEEKLY WEIGHTS
COMMENTS:
MOOD / EMOTIONS
HAS A PRN PROTOCOLfor MEDICATION / GENERALLY STABLE MOOD / EMOTIONS / NO MEDICATIONS REQUIRED
SOME DIFFICULTY WITH MOOD / EMOTIONS / COPES WITH 1:1 EMOTIONAL SUPPORT FROM TEAM
MOOD / EMOTIONS AFFECT COPING AT TIMES / REQUIRES PRN MEDICATION TO SUPPORT MOOD
MOOD / EMOTIONS AFFECT COPING DAILY / REGULAR MEDICATION / PROFESSIONAL SUPPORT
COMMENTS:
CONTINENCE
URINARY / BOWEL
HAS A SUPPORT PLAN for TOILETING / FULLY CONTINENT / NO CONCERNS / REQUIRES NO SUPERVISION OR SUPPORT
OCCASIONAL INCONTINENCE / NO PADS / REQUIRES REMINDERS TO TOILET
INCONTINENT OF URINE ONLY / DAY PADS / REQUIRES SUPPORT WITH TOILETING
TOTAL INCONTINENCE / DAY & NIGHT PADS / REQUIRES 1:1 ASSISTANCE WITH ALL TOILETING
COMMENTS:
SOCIABILITY &
RELATIONSHIPS
HAS A SUPPORT PLAN / SOCIAL / GOOD INTERPERSONAL RELATIONSHIPS / COMPATIBLE WITH MANY PEOPLE
OCCASIONALLY WITHDRAWS / HAS CONFLICTS / COPES WITH HELP OF SUPPORTIVE FRIENDS
FREQUENTLY WITHDRAWS / HAS CONFLICTS / REQUIRES DAILY TEAM SUPPORT TO COPE
WITHDRAWS DAILY / HAS CONFLICTS DAILY / REQUIRES PROFESSIONAL SUPPORT TO COPE
COMMENTS:
MEMORY &
CONCENTRATION
HAS A SUPPORT PLAN / EXCELLENT MEMORY OF LIFE EVENTS / EASILY ABLE TO FOCUS AND CONCENTRATE
GENERALLY GOOD MEMORY OF LIFE EVENTS / FOCUS & CONCENTRATION ARE AFFECTED BY MOOD
POOR SHORT TERM (RECENT) MEMORY / POOR CONCENTRATION / EASILY DISTRACTED
NO SHORT TERM MEMORY / LOSING OWN HISTORY / UNABLE TO FOCUS AND CONCENTRATE
COMMENTS:

BASELINE FOR DAILY JOURNAL PG 2

FOCUS AREA / HIGHLIGHT ALL STATEMENTS IDENTIFYING
THE ‘USUAL’ EXPECTATION
MOBILITY
HAS AN EXERCISE SUPPORT PLAN / WALKS INDEPENDENTLY / NOT AT RISK FOR FALLS DUE TO MOBILITY
REQUIRES MONITORING WHEN WALKING / AT MODERATE RISK FOR FALLS DUE TO MOBILITY
USES CANE OR WALKER WHEN WALKING / REQUIRES 1:1 SUPPORT TO AMBULATE SAFELY
UNABLE TO AMBULATE / USES WHEELCHAIR / AT HIGHRISKSFORFALLS / SUPERVISED + +
COMMENTS:
ENERGY ANXIETY, AGITATION, AGGRESSION
HAS A BEHAVIOUR PROTOCOL / GENERALLY PEACEFUL AND CALM ENERGY / RARELY UPSET OR AGITATED
OCCASIONALLY ANXIOUS / AGITATED / PACING / AFFECTED BY CHANGES TO DAILY ROUTINE
FREQUENTLY ANXIOUS / AGITATED / PACING / ANXIOUS / AGITATED IN : MORN / AFT / EVE
VERBALLY / PHYSICALLY AGGRESSIVE AT TIMES / REQUIRES PROFESSIONAL SUPPORT / MEDICATION
COMMENTS:
FUNCTIONAL ABILITY &
SELF-CARE (ADL’S)
HAS A SUPPORT PLAN / INDEPENDENT WITH ALL SELF-CARE (ADL’S) / GOES INDEPENDENTLY TO DAY PROGRAM / HOME
INDEPENDENT BUT NEEDS REMINDERS / PROMPTS / USES HANDIDART TO DAY PROGRAM / HOME
NEEDS 1:1 SUPPORT WITH MAJOR SELF-CARE TASKS / TAKEN BY TEAM MEMBER TO DAY PROGRAM / HOME
NEEDS 1:1 SUPPORT WITH ALL SELF-CARE TASKS / DOES NOT GO TO WORK / DAY PROGRAM
COMMENTS:
ADDED INFORMATION REGARDING THESE 3 FOCUS AREAS THAT ONLY REQUIRE DOCUMENTAION ON THE DAILY JOURNAL WHEN THERE IS SOMETHING TO REPORT
SEIZURES
HAS A SEIZURE PROTOCOL / NO HISTORY OF SEIZURES / NO SEIZURE ACTIVITY / RARE SEIZURE ACTIVITY
PREVIOUS REPORTED HISTORY OF SEIZURES / HAS 1 OR MORE SEIZURES MONTHLY
EXPERIENCES SEIZURES: MILD / SHORT / HAS 1 OR MORE SEIZURE WEEKLY
EXPERIENCES SEIZURES: SEVERE / LONG / HAS 1 OR MORE SEIZURES DAILY
COMMENTS:
MENSTRUATION /
MENOPAUSE
HAS A SUPPORT PLAN / MALE – DOES NOT HAVE MENSTRUAL CYCLE / NO MONITORING OR SUPPORT NEEDED MONTHLY
NO MENSES DUE TO HYSTERECTOMY / MENOPAUSE / EXPERIENCES VERY LITTLE DISCOMFORT
MENSES: MONTHLY & REGULAR / IRREGULAR / EXPERIENCES MENSTRUAL CRAMPS / PRN MEDS
SELF-CARE SUPPORT NEEDED DURING MENSES / ON BIRTH CONTROL PILL / HORMONE REPLACEMENT
COMMENTS:
BOWEL RECORD
HAS A BOWEL CARE PLAN / REGULAR BM DAILY / NO MONITORING OR SUPPORT NEEDED
HAS OCCASIONAL CONSTIPATED / LOOSE BM’S / ASKS FOR SUPPORT WHEN NEEDED
HAS FREQUENT CONSTIPATED / LOOSE BM’S / REQUIRES MONITORING REGULARLY
HAS BOWEL RELATED CONCERNS / ILLNESS / REQUIRES CLOSE SUPERVISION / SUPPORT DAILY
COMMENTS:

NOTE: WHEN THIS BASELINE REQUIRES UPDATING, COMPLETE A NEW ONE AND THEN FILE THIS ONE IN THE ‘DAILY JOURNAL HISTORY’ BINDER, IN THE HOME.