Important: These templates are starting points to help you organise your observations. They are not legal advice or professional advocacy services. For advice specific to your circumstances, consult a solicitor or professional CHC advocate.

CHC Funding Guide

The assessors need evidence.
Here's exactly what to record.

A CHC assessment is won or lost on the quality of the evidence presented. The Multi-Disciplinary Team scores each of the 12 care domains based on what they can see in the records. If something isn't documented, it effectively didn't happen.

These templates show you what to record, how to phrase it, and why it matters — domain by domain.

The care diary: your most powerful tool

A care diaryis a dated, factual record of your loved one's care needs written by someone who sees them regularly — usually a family member. It is not a complaint, a narrative, or an opinion piece. It is evidence.

What makes a strong care diary entry

  • +Date and time of the observation or incident
  • +What happened — factual, specific, no editorialising
  • +How long it lasted or how many staff were involved
  • +What intervention was required (medication, restraint, two-person assist)
  • +What the outcome was (did they settle? was it repeated later?)
  • +Which DST domain it relates to (behaviour, cognition, mobility, etc.)

Avoid these common mistakes

  • -Vague statements: "Mum had a bad day" tells the assessor nothing
  • -Emotional language: "It's disgusting that nobody cares" undermines your credibility
  • -Generalising: "She falls all the time" — how many times? When? What happened?
  • -Mixing needs with complaints about the care home — keep these separate

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All 12 DST domains with prompts
Example entries for each domain
Guidance on what assessors look for

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Domain-by-domain: what to record

The Decision Support Tool has 12 care domains. For each one, the MDT panel scores the person's needs as No needs, Low, Moderate, High, Severe, or Priority. To qualify for CHC, a person typically needs at least one Severe rating or several Highs across multiple domains.

Below is what to record for each domain, with example phrasing you can adapt.

1

Behaviour

What to look for

Aggression, agitation, wandering, resistance to care, self-harm, sundowning episodes

What to record

Date, time, trigger (if known), duration, what staff had to do, was restraint or PRN medication used?

Example entry

"14 Jan — 2:45pm: Mum became agitated during personal care, struck carer's arm, required two staff for 25 minutes. PRN lorazepam administered at 3:10pm. Settled by 3:40pm."
2

Cognition

What to look for

Disorientation, inability to make decisions, failure to recognise family, getting lost in familiar environments

What to record

Specific instances where cognitive impairment created a risk or required intervention

Example entry

"18 Jan — Found in the corridor at 1am, did not recognise her room. Tried to leave the building. Staff redirected her three times before she settled. Took 40 minutes."
3

Communication

What to look for

Inability to express needs, difficulty understanding instructions, use of non-verbal cues only

What to record

How communication breakdown affected care delivery or caused distress

Example entry

"22 Jan — Unable to tell staff she was in pain. Carer noticed facial grimacing during repositioning. GP called — diagnosed UTI. Pain had likely been present for 2+ days."
4

Psychological / Emotional

What to look for

Depression, anxiety, hallucinations, delusions, emotional lability, withdrawal from activities

What to record

Frequency and impact on daily functioning, interventions required, mental health professional involvement

Example entry

"25 Jan — Believed strangers were in her room. Became extremely distressed, crying and shouting. Staff sat with her for 45 minutes. Happened 3 times this week."
5

Mobility

What to look for

Falls, inability to transfer, requirement for hoisting, unsafe walking, contractures

What to record

Number of falls per week/month, number of staff needed for transfers, equipment used, time taken

Example entry

"Falls log: 4 falls in January. Two required A&E attendance. All transfers now require full-body hoist with two carers (15 minutes per transfer, 6 transfers/day)."
6

Nutrition

What to look for

PEG feeding, thickened fluids, swallowing difficulties (dysphagia), weight loss, risk of aspiration

What to record

SALT assessment outcome, modified diet details, percentage of meals eaten, weight trajectory

Example entry

"SALT assessment 10 Jan: Level 4 puree diet, Level 2 mildly thick fluids. Coughing observed during 3 of 5 meals this week. Weight dropped from 52kg to 48kg in 6 weeks."
7

Continence

What to look for

Double incontinence, catheter management, skin breakdown from incontinence, frequency of pad changes

What to record

Number of incontinence episodes per day/night, skin condition, pad type and change frequency

Example entry

"Doubly incontinent — 6-8 pad changes per 24 hours. Developed grade 2 pressure sore on sacrum (documented in tissue viability assessment 12 Jan). Requires barrier cream application at each change."
8

Skin Integrity

What to look for

Pressure sores, wound care, skin tears, requirement for pressure-relieving equipment

What to record

Wound assessments, grade of pressure sores, frequency of dressing changes, equipment in use

Example entry

"Grade 3 pressure sore left heel — daily dressing by district nurse. Air-flow mattress and 2-hourly repositioning schedule. Wound not healing — referred to tissue viability nurse 20 Jan."
9

Breathing

What to look for

Oxygen therapy, COPD management, nebulisers, suction, sleep apnoea requiring intervention

What to record

Oxygen saturation readings, nebuliser frequency, hospital admissions for respiratory issues

Example entry

"On 2L oxygen 24/7. Nebulisers x4 daily. Two emergency admissions for COPD exacerbation in last 3 months. Sats drop to 82% without oxygen."
10

Drug Therapies

What to look for

Complex medication regimens, injections, covert medication, monitoring requirements, adverse reactions

What to record

Number of medications, administration method, frequency, clinical monitoring needed

Example entry

"18 medications including twice-daily insulin injections, weekly INR monitoring for warfarin, and covert medication in food (authorised under best interests decision 8 Jan). Adverse reaction to new antibiotic on 15 Jan — required GP visit."
11

Altered States of Consciousness

What to look for

Seizures, loss of consciousness, delirium, fluctuating awareness

What to record

Frequency, duration, post-episode recovery time, emergency interventions required

Example entry

"Tonic-clonic seizure 28 Jan, lasted 4 minutes. Buccal midazolam administered. Post-ictal confusion for 3 hours. Third seizure this month despite medication adjustment."
12

Other Significant Needs

What to look for

Anything not captured above — e.g., tracheostomy care, stoma care, dialysis, complex pain management

What to record

Clinical procedures required, frequency, specialist involvement, impact on daily life

Example entry

"Stoma care requires trained nurse twice daily — site prone to infection (treated with antibiotics 3 times in 6 months). Pain management via syringe driver reviewed weekly by palliative care consultant."

The incident log: tracking patterns over time

An incident log differs from a care diary. While the diary captures daily observations, the incident log tracks specific eventsthat demonstrate the nature, complexity, intensity, and unpredictability of your loved one's needs — the four characteristics the MDT uses to determine a primary health need.

What counts as an incident

  • +Falls (including near-misses)
  • +Hospital or A&E admissions
  • +Behavioural episodes requiring restraint or PRN medication
  • +Choking or aspiration events
  • +Seizures or loss of consciousness
  • +Infections requiring antibiotics (UTIs, chest infections, wound infections)
  • +Significant changes in condition (sudden deterioration, delirium)
  • +Absconding or wandering incidents

The power of an incident log is in the pattern it reveals. Three falls in a month is a stronger statement about mobility needs than a single assessment snapshot. Seven UTIs in six months tells a story about continence management that a one-off observation misses. Assessors are trained to look at the totality of needs — your incident log makes that totality visible.

Template letters you may need

At various stages of the CHC process, you may need to write formal letters to the ICB, the care home, or your GP. Here are the most common situations and what each letter should include.

Requesting a CHC Checklist screening

When: When you believe your loved one may qualify for CHC but no screening has been done

Your letter should include:

  • +The person's name, date of birth, and NHS number
  • +A brief summary of their care needs (referencing DST domains)
  • +A request for a Checklist screening under the NHS National Framework (2022)
  • +Your relationship to the individual and contact details

Requesting access to care home records

When: When you need daily care records, incident logs, or care plans for the assessment

Your letter should include:

  • +Cite the Data Protection Act 2018 and UK GDPR (Article 15)
  • +Specify which records you need (daily notes, incident reports, care plans)
  • +State your legal basis (LPA, next of kin, court-appointed deputy)
  • +Give a reasonable deadline (30 days is the statutory maximum)

Submitting evidence to the MDT panel

When: Before the full assessment meeting, to ensure your evidence is on the record

Your letter should include:

  • +A covering letter listing all enclosed documents
  • +Your care diary (organised by domain)
  • +Your incident log
  • +Any supporting clinical documents you've gathered
  • +A request for confirmation that these will be circulated to all MDT members before the meeting

Challenging a CHC decision

When: When the assessment outcome is negative and you believe it was incorrect

Your letter should include:

  • +The date of the decision and reference number
  • +Specific domains where you believe the scoring was wrong, with evidence
  • +Reference to the NHS National Framework (2022) and the relevant scoring descriptors
  • +A request for a local review or referral to the Independent Review Panel
Full appeals guide

Common questions

What evidence is needed for a CHC assessment?

The Multi-Disciplinary Team (MDT) panel considers clinical records (GP notes, hospital discharge summaries, consultant letters), care home daily records, your own care diary, and any professional assessments (physiotherapy, speech therapy, mental health). The strongest cases include specific, dated examples of care needs across the 12 DST domains.

Can family members submit evidence to the CHC assessment?

Yes. The NHS National Framework (2022) states that the individual and their family should be invited to contribute to the assessment and that their views must be recorded. You can submit a written statement, a care diary, and supporting documents. The MDT must consider this evidence alongside clinical records.

How far in advance should I start gathering evidence?

Start as soon as you know a CHC assessment is being arranged — ideally 2-4 weeks before the MDT meeting. However, even if the meeting is imminent, any evidence you can provide is valuable. If you are requesting a retrospective review, you may need to gather historical records going back months or years.

What if the care home won't share daily records with us?

You have the right to request these records under UK GDPR. If the individual lacks capacity, the person with Lasting Power of Attorney (Health and Welfare) or a court-appointed deputy can request them. If the care home refuses, put your request in writing citing the Data Protection Act 2018 and escalate to the ICO if necessary.

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