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Apex Care's Daily Notes
• To be submitted prior to 0900 hrs daily without fail.
• These notes are shared with the other people supporting the tangata whai ora. This can include:
- Judges - these Notes can be used in a court of law
- Social Worker - has to know what is happening with their tangata daily
- Customer Main Office - need to know we are doing what they are paying us for, and understand any problems.
• Expectation is that the Notes are clear, concise with good grammar and punctuation used. They must be legible to anyone reading them so they understand exactly what has happened.
• Your Daily Notes form a legal representation to the customer on what happened on shift, so be professional.
• Do not input slang or other language or text speak.
• When completed, please click the Submit button at the bottom.
* means mandatory
REMINDER: SITE SAFETY CHECKS:
• Have you done your Site Safety Check inside and outside of the premises?
• Required for first time on site or a refresher when you haven't been there for a while.
• Always healthy to do a quick site check on mornings throughout your shift.
• Found here: www.apexcarenz.com/resources.
Tangata Whaiora Name / Person in your care
*
First
Last
Please write the first name in full and the last name can be just the Initial.
If you supported the whole house, please write WHOLE for first name and HOUSE for last name. You do not need to name all individuals.
Kaimahi / Your Name
*
First
Last
Date of support provided
*
DD
/
MM
/
YYYY
SHIFT TIMES:
• PLEASE USE THE 24 HOUR CLOCK e.g. 0700-1500 etc. Do NOT use am or pm.
• If you wish, you can also include the sleepover notes as part of the day's Daily Notes e.g. 0600-2200 hrs / sleepover 2200-0600 hrs.
• However, you cannot amalgamate all your shifts into 1 - each day is separate.
• Do not enter the amount of hours worked, specify the times.
• Must match WIW - if not, please call 0800 255 000 and work out the discrepancy.
*
Customer's name e.g. ICAMHS, OT, TRT, Private - This is found on your WIW shift under position.
Do not default to just any name as this can mean the notes going to the wrong customer.
*
Location of support
*
Name of the house is okay, or just street/road name.
Important Info for kaimahi e.g. appointments coming up, etc.
*
SECTION A: MEDICATION AND MEALS
MEDICATION:
• Was medication taken, name and how much/dose?
• If 2 kaimahi on site, the one giving the meds lists them.
• The other kaimahi is to select the "Medication observed given as charted" to show you saw them been given and taken.
• Whenever you pick up meds from a pharmacy, ensure you get a corresponding signing sheet.
Please call 0800 255 000:
• If you are running low on signing sheets, or weren’t given any.
• If meds are low i.e. a week remaining and no more repeats.
Were all medications given as charted?
*
Yes
No
No medication required
Medication observed given as charted
Morning - meds given, dose and time
Time
HH
:
MM
AM
PM
AM/PM
Lunch- meds given, dose and time
Time
HH
:
MM
AM
PM
AM/PM
Dinner/Tea - meds given, dose and time
Time
HH
:
MM
AM
PM
AM/PM
If meds refused / not taken, please enter why?
You can upload the Medication Signing Sheet here. This can be done last day of shift or on a Sunday
If you take any photos of the medications for this purpose, the photo must be deleted off your phone straight away due to confidentiality.
MEALS:
• Enter WHAT they ate, not just that they ate
• If they did not eat anything then - None
• If you were not on shift for this meal then - N/A
Breakfast
*
Lunch
*
Dinner
*
Snacks / Water
DAILY NOTES :
Two sections:
- Section B: Daily Events
- Section C: Your Observations using Te Whare Tapa Wha model
For Both:
• Use initials for the tangata name; write words not text speak; use punctuation; review before pressing submit.
• Notes should be specific, detailed and factual about what you observed of ALL the events of the day, and be tangata whaiora focussed.
• Remember, these Notes can be used in court by our customer, so need to be professional and legible to anyone.
• If there is an incident on site, please fill in the Incident form found at: www.apexcarenz.com/resources.
Personal opinions or comments should be kept to Section D if you have any.
SECTION B: DAILY EVENTS
Enter in all daily activity, preferably list by time so we can see the chronological events of the day.
DAILY NOTES
*
SECTION C: OBSERVATIONS USING TE WHARE TAPA WHA MODEL
To help understand the tangata more, your observations are crucial for insight and understanding.
• Using the Te Whare Tapa Wha health model, we are requesting the information to be broken down into 4 of the dimensions.
• We also are asking you to give a rating based upon the tangata responses during your shifts. This helps us look for trends or anything we can spot that may need addressing.
1 = NA / 2 = poor / 3 = could do better / 4 = average / 5 = doing well / 6 = excellent
Taha Hinengaro / Mental Wellbeing NOTES:
Examples are: Distress signs, early warning signs, anxieties, feelings/emotions
Taha Hinengaro / Mental Wellbeing RATING:
 
Poor
1
2
3
4
5
6
 
Best
1 = NA / 2 = poor / 3 = could do better / 4 = average / 5 = doing well / 6 = excellent
Where you select 1 is that you have absolutely no feedback on this. If you have provided Notes in this section, you must give a rating.
Taha Tinana / Physical Wellbeing NOTES:
Examples are: Physical appearance, hygiene, clothing, health concerns e.g. wounds, any medical symptoms of concern like pain, vomiting, urinary frequency, diarrhoea etc., nutrition
Taha Tinana / Physical Wellbeing RATING:
 
Poor
1
2
3
4
5
6
 
Best
1 = NA / 2 = poor / 3 = could do better / 4 = average / 5 = doing well / 6 = excellent
Where you select 1 is that you have absolutely no feedback on this. If you have provided Notes in this section, you must give a rating.
Taha Whānau / Social Wellbeing NOTES:
Examples are: Whānau contact, community contact, appointments.
Taha Whānau / Social Wellbeing RATING:
 
Poor
1
2
3
4
5
6
 
Best
1 = NA / 2 = poor / 3 = could do better / 4 = average / 5 = doing well / 6 = excellent
Where you select 1 is that you have absolutely no feedback on this. If you have provided Notes in this section, you must give a rating.
Taha Wairua / Spiritual Essence / Environmental Wellbeing NOTES:
Examples are: Home and surrounds, health & safety
Taha Wairua / Spiritual Essence RATING:
 
Poor
1
2
3
4
5
6
 
Best
1 = NA / 2 = poor / 3 = could do better / 4 = average / 5 = doing well / 6 = excellent
Where you select 1 is that you have absolutely no feedback on this. If you have provided Notes in this section, you must give a rating.
SECTION D: YOUR PERSONAL FEEDBACK / OPINION
Your Personal Feedback to Apex Office - this is where you can make personal notes for us to follow-up on or raise concerns.
Or you can use the Concerns Form: https://www.apexcarenz.com/information