CYS Observation Report

Staff Name*

First NameLast Name

Date*

Date

Child's Name*

First NameLast Name

Child's Name

First NameLast Name

Child's Name

First NameLast Name

Child's Name

First NameLast Name

Location of Activity/Supervised Visitation*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Program/Transition *

Time log of shift events

Setting Conditions *

What is the environment like? What is the parents physical appearance, behaviour & demeanour (overall conduct)? What domestic activities were conducted by staff/parent?

Child/rens Behaviour*

Emotional state of mind

Strategies used to engage*

List any strategies you used e.g. active listening, redirection, affirmation etc.

Therapeutic Events*

List any clinical or therapist interaction.

Family & other stakeholder contacts*

What other people were present during the shift?

Health, hygiene & personal care*

Your observations of the physical condition of the child/ren. Did you need to conduct any personal care?

Community Access & Activity Undertaken*

What activity did you do with the child/ren? Do the child/ren have any other social interests?

Client Request*

Did the child/ren request anything during your shift?

Medication Administration*

Medication administration to be documented in the following format: Time administered, 8R’s completed, administration code, medication name If medication administration is not required document n/a

The 8 R’s of medication administration:
Right Person
Right Medication
Right Dose
Right Route
Right Time
Right Documentation
Right Reason
Right Response

Medication administration codes:
P - prompted
A - assisted
AD - administered
D - declined
T - taken by client but not witnessed
M - missing
F - fasting
CA - client away
W - withheld

Observations & Improvements*

Has anything improved/declined since your last shift with child/ren? Do you have any further feedback or observations of parents or child/ren?

Signature

Child Services Observation Report