Sample report. Invented person and details.
Daily care report
Mrs A. O., 78 · High blood pressure, type 2 diabetes
Tuesday · Morning visit, 06:30 to 09:00 · Caregiver clocked in 06:28 at the home address
Vitals
Blood pressure128/82 mmHgIn rangeAgreed range 100 to 140 / 60 to 90
Pulse74 per minuteIn rangeAgreed range 60 to 100
Temperature36.8 °CIn rangeAgreed range 36.1 to 37.5
Blood sugar, before breakfast6.4 mmol/LIn rangeAgreed range 4 to 8
Ranges are set for each person from their doctor's advice. A reading outside the range goes to the nurse straight away.
Medication
| Medicine | Time | How | Status |
|---|---|---|---|
| Amlodipine 5 mg | 08:05 | Prompted, taken with water | Given |
| Metformin 500 mg | 08:05 | Prompted, taken with breakfast | Given |
| Vitamin D 1000 IU | 08:05 | Prompted | Given |
Only medicines prescribed by her doctor appear here. A missed dose is flagged to the nurse the same day.
The visit
- Breakfast
- Pap and akara. Ate most of it.
- Drinks
- Two cups of water and one cup of tea by 09:00.
- Personal care
- Bath with help. Skin checked, no sore areas.
- Mobility
- Walked to the garden and back with support. No falls.
- Mood
- Cheerful. Spoke with her daughter on a video call and asked about the grandchildren.
- Incidents
- None.
Notes
Caregiver
Her left knee was stiff when she got up. It eased after walking. I will check it again tomorrow.
Nurse
Knee stiffness noted. It was first recorded in March and has not changed. Watch for swelling. No change to the care plan.