2. Determine new triggers to behaviour and implement interventions via the behaviour monitoring outcome form. 3. Continue monitoring the behaviour for up to 7 days to determine the effectiveness of interventions used. When What? Where? Who? Why? How? When did it happen What behaviour was observed? Be specific. Where did the behaviour occur? Who else was present? What else was happening? What may have caused or triggered the behaviour? How did others/staff respond to the behaviour? How did the resident react? date time e. If you have identified any behaviors of concern with Mr.Stan such as physical aggressive behavior and if you think the behavior might be a risk to staff/others, fill in the behavior of concern incident form.
25 | P a g e Star_CHCAGE005_Student_Assessment_Workbook_2019_v1.2 STAR Health Care Behaviour of Concern Incident Form NAME Jo Surname Stan Sex: Male DOB May 29, 1935 MRN/CRN MRN: 12545626 Diagnosis Dementia Date: Time: Name of the person completing the form Designation Does the resident/patient have a pre- existing behavioural problem? Yes No Has the resident been aggressive before: Yes No Tick the most appropriate type of behaviour involved: Punch Hit Scratch Kick Spit Trip Yelling Racial Abuse Bite Grabing Pushing Throwing Objects Hair Pulling Bent Fingers Back Sexual Harassment Touching Unwelcomed Sexual Comments Abusive/offensive comments other. Tick what activity you were engaged in when the challenging behaviour occurred? Feeding Lifting Turning Dressing/Undressing Transfer/Transporting Bathing Grooming Awaken from Sleep Toileting Redirecting Other Activity __________________________________
26 | P a g e Star_CHCAGE005_Student_Assessment_Workbook_2019_v1.2 Was there a trigger to this behaviour/ Incident? Yes No Did the resident appear anxious or agitated prior to incident? Is the resident on regular sedative/ psychotropic medication? Was Patient asleep? Did you wake the patient? Was the patient regularly turned for skin Integrity Was the patient disturbed by staff or another resident? Is the resident in Pain? Has the resident been given Pain relief? Did you give full attention to the patient or were you talking to your Partner (co-worker)? Was the patient engaged in an activity not wanting to be disturbed? Any Other please define ________________________________________________ Indicate the seriousness of the incident from your perspective by circling the appropriate number 0 (not at all serious) 1 2 3 4 5 (extremely serious) Were you or others injured? Yes, No Would you like to talk about this Incident? Yes No Have you reported/discussed about this Incident with the RN? Yes No Have you completed all the documentation and updated the NCP? Yes No Has the incident been reported to the LMO? Yes Date: ________________________ Name: Signature: Date: H . Student to identify the Variations and the frequency of physical behaviour of Mr. Stan and to use appropriate codes to document the behaviour identified and initial at the appropriate time identified. This form is to be used by student when the trainer states to commence on ACFI assessments for Funding.
- One '17
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