Behaviour Analysis Chart
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1FAMILY NAME
MRN
GIVEN NAME
MALE
FEMALE
HUNTER NEW ENGLAND LOCAL HEALTH DISTRICT
D.O.B. ___ / ___ / ____
M.O.
Facility: _______________________
ADDRESS
BEHAVIOUR ANALYSIS CHART
This chart can be used by all clinicians to document behaviours (including behavioural
●
and psychological symptoms of dementia) that occur in acute or MPS settings. This
LOCATION / WARD
Information will assist in identifying the cause of the behaviour and in the development
of management strategies to minimise the impact of the behaviour on the patient/
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
resident, other patients/residents and staff, if applicable.
●
Date of incident: ______________
Time of incident ______________
●
Is this a change from the person’s usual behaviour?
Yes
No Did the behaviour have a rapid onset?
Yes
No
●
(If Yes to either of these question, consider the person may have a delirium and follow the CPG – Management of Delirium in acute settings)
●
How often does the behaviour occur?
Daily/ more than once per day/ weekly/ more than once per week/monthly
●
Is the person confused?
Yes
No
Does the confusion fluctuate?
Yes
No
●
Where did the behaviour occur?
●
Toilet
Bathroom
Bedroom/ward
Lounge/recreation area
Dining room
Other
__________________________________________________________________________________________________________
Who was involved during the incident? (Please specify names and relationship to person)
__________________________________________________________________________________________________________
What happened prior to the behaviour occurring?
Medical treatment
Personal care
Toileting
Social contact
Outing
Distressing news
Other (please specify) _____________________________________________________________________________________
Describe what occurred during the incident – be factual:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Were there any possible triggers for the behaviour?
Nursing or medical intervention
acute/worsening medical condition
Pain
Frustration
Over/under stimulation
Other (please specify) __________________________________________________
What actions/intervention were provided by staff at the time?
●
Reassurance
Removal to another area
Validation and/or reality orientation
Medication/analgesia
●
●
Food/drink
Other (please specify) ________________________________________________________________
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What was the person’s response to staff’s interventions?
●
Return to usual behaviour/settled
Remained agitated
Upset/crying
Withdrawn
●
Other (please specify) ___________________________________________________________________________________
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What further assessment/investigations have been attended in response to this incident?
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Observations
Urinalysis (?MSU)
BGL
Pain assess
Check bowel chart
CAMI
Referral – Medical review / Geriatrician /Dementia Advisor / SMHSOP / DBMAS / AARCS (please circle)
MMSE
Geriatric Depression Scale
Discussion with carers or family members
Name:________________________________ Designation: ______________ Signature: _______________ Date: ________
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