SIL Progress Notes

Notes: This field is used to input the notes applicable with the SIL Service. Information can be specified in summary form or detail. Information can include details of the service activities and supports provided, concerns and notifications necessary for handover as well as the comments on the client.

Client: This field reflects the particulars of the client associated with the SIL Shift Note.

Service Schedule: This field reflects the particulars of the SIL service associated with the SIL Shift Note.

General Daily Case Notes: This field is used to input the notes applicable with the SIL Service. Information can be specified in summary form or detail. Information can include details of the service activities and supports provided, concerns and notifications necessary for handover as well as the comments on the client.

AM Medication Administered: This field is used to identify whether the clients morning medications where administered. Options include Yes, No and Declined.

AM Medication Administration Time: This field identifies the medication administered time.

Staff Name: This field lists the particulars of the staff member that administered the clients medications.

Midday Medication Administered: This field is used to identify whether the clients midday medications where administered. Options include Yes, No and Declined.

Midday Medication Administration Time: This field identifies the medication administered time.

Staff Name: This field lists the particulars of the staff member that administered the clients medications.

PM Medication Administered: This field is used to identify whether the clients afternoon medications where administered. Options include Yes, No and Declined.

PM Medication Administration Time: This field is used to specify the medication administered time.

Staff Name: This field lists the particulars of the staff member that administered the clients medications.

Evening Medication Administered: This field is used to identify whether the clients evening medications where administered. Options include Yes, No and Declined.

Evening Medication Administration Time: This field identifies the medication administered time

Staff Name: This field lists the particulars of the staff member that administered the clients medications.

Breakfast Menu followed: This field is used to acknowledge a standard menu was observed.

Breakfast Completion: This field is used to specify the level of assistance required or whether the meal was refused or completed independently.

What was eaten for breakfast: This field is used to specify the food eaten during the meal service.

Lunch Menu followed: This field is used to acknowledge a standard menu was observed.

Lunch Completion: This field is used to specify the level of assistance required or whether the meal was refused or completed independently.

What was eaten for lunch: This field is used to specify the food eaten during the meal service.

Dinner Menu followed: This field is used to acknowledge a standard menu was observed.

Dinner Completion: This field is used to specify the level of assistance required or whether the meal was refused or completed independently.

What was eaten for dinner: This field is used to specify the food eaten during the meal service.

Snacks Menu followed: This field is used to acknowledge a standard menu was observed.

Snacks Completion: This field is used to specify the level of assistance required or whether the meal was refused or completed independently.

Snack: This field is used to specify the food eaten as snack during the meal services.

Shower/Bath Completed AM: This field is used to identify if the client showered in the AM

Shower/Bath Completed PM: This field is used to identify if the client showered in the PM

Shower/Bath Completion: This field is used to specify the level of assistance required or whether the shower was refused or the client completed the activity independently.

Brushing Teeth Completed AM: This field is used to identify if the client undertook oral care in the AM

Brushing Teeth Completed PM: This field is used to identify if the client undertook oral care in the PM

Brushing Teeth Completion: This field is used to specify the level of assistance required or whether the oral care was refused or the client completed the activity independently.

Changing clothes completed AM: This field is used to identify if the client changed their clothes in the AM

Changing clothes completed PM: This field is used to identify if the client changed their clothes in the PM.

Changing clothes Completion: This field is used to specify the level of assistance required or whether a change of clothing was refused or the client completed the activity independently.

Toileting Completed AM: This field is used to identify if the client toileted in the AM.

Toileting Completed PM: This field is used to identify if the client toileted in the PM.

Toileting Completion: This field is used to specify the level of assistance required or whether the toileting was refused or the client completed the activity independently.

Personal Grooming completed AM: This field is used to identify if the client completed grooming activities in the AM.

Personal Grooming completed PM: This field is used to identify if the client completed grooming activities in the PM.

Personal grooming Completion: This field is used to specify the level of assistance required or whether the personal grooming was refused or the client completed the activity independently.

Hygiene Log general comments: This field provides a summary of or detailed notes related with with personal hygiene activities undertaken during the SIL Service.

Start Time: This field is used to specify the commencement time of a community activity.

Finish Time: This field is used to specify the cessation time of a community activity.

Supervised or unsupervised: This field is used to specify the supervision arrangements.

Planned or unplanned: This field is used specify the planning arrangements

Purpose of Access: This field is used to categorise the nature of the community access activity

Method of transport: This field is used to categorise the method of transport used in relation to the community access activity.

How much support was needed in the community: This field is used to specify the level of assistance required or whether the community access was refused or the client completed the activity independently.

Health/Therapy provider: This field is used to specify the particulars of the healthcare or Allied health provider appointment.

Agency: This field is used to specify the particulars of a nominated agency.

Supervised/ unsupervised: This field is used to specify the supervision arrangements with respect to the appointment.

Planned/ emergency: This field is used specify the planning arrangements in relation to the appointment.

Follow Up Needed: This field is used to specify any follow up actions healthcare or Allied health provider appointment.

Were any restrictive practices used today: This field is used to specify whether a restrictive practice was used during the service

What were used: This field details the nature of the restrictive practice used during the service.

Distorted thinking: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Fears and Phobias: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Binging/overeating food: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Purging/vomiting after eating: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Declined to eat: Specify yes if behaviour was demonstrated during service , otherwise leave set as No. Ensure the refusal has already been specified.

Difficulties with communicating with participants: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Lost interest/motivation preferred activities: Specify yes if behaviour was demonstrated during service , otherwise leave set as No. Ensure the refusal has already been specified.

Declined attend scheduled supports appts activities: Specify yes if behaviour was demonstrated during service , otherwise leave set as No. Ensure the refusal has already been specified.

Signs of illness: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Verbal aggression: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Anxiety: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Unable to self-manage own emotions: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Distress/crying/worrying: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Obsessions or compulsions: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Oppositional/defiant behaviour: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Seeking attention of emergency services: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Somatising/ complain of being unwell but in good health: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Agitation/hyperarousal/ unusually heightened state: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Fluctuating mood changes: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Non-engagement/task refusal: Specify yes if behaviour was demonstrated during service , otherwise leave set as No. Ensure the refusal has already been specified.

Behaviour that places participant or others at risk of harm: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Alcohol Use: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Socially inappropriate sexual acts: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Consensual, age appropriate sexual activity: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Property damage: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Absconding or wandering: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Behaviour that would require a criminal justice response: Specify yes if a behaviour resulted in a response from the police, otherwise leave set as No.

Declined medication: Specify yes if behaviour was demonstrated during service , otherwise leave set as No. Ensure a refusal of medication has already been specified.

Self-injury - thoughts or statements: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Suicidal Ideation – thoughts or statements : Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Self-injury - acts: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Suicidal planning or attempt: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Illicit substance use: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Use of non-prescribed over counter medication: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Physical aggression: Specify yes if behaviour was demonstrated during service , otherwise leave set as No.

Other: This field is used to specified the behaviour demonstrated by the client that is not listed in the available selections.

Additional Comments about Behaviours of Concern: This field is used to specify in summary or details additional comments related with the behaviour displayed by the client during the service.