Root Cause Identification & Tracking Journal
Your Name
First Name
Last Name
Patient Name
Date of incident:
/
Month
/
Day
Year
Date
Approximate time of incident:
Hour Minutes
AM
PM
AM/PM Option
Memory Care Coach
Please Select
Christabel Smith
Brianna Kaminski
Stacey Bergmann
Dahlia Klein
Kaylee Magee
Faithe Bland
Priya Rathee
Please select your coach.
Please describe what happened.
Please list anyone present and their relationship to the patient.
Please identify anyone directly involved.
What was happening just before the behavior occurred?
Who was affected by the behavior?
What emotions did your loved one express? (fear, frustration, sadness, etc)
How did you / caregiver respond?
Did your / caregiver's approach successfully redirect the behavior? What happened?
Was your loved one active that day?
Did your loved one nap during the day?
Did your loved one sleep well the night before?
Has medication been changed at all?
Has your loved one been eating or drinking enough?
Have bowel & bladder habits been regular?
Has anything changed in your loved one's environement?
What do you suspect triggered your loved one's behavioral expression?
Please rate your stress following the incident.
1 = not stressed through 10 = extremely stressed
Please share any additional details or feelings you may be having following this event.
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