Page 318 - tmp

Progress Notes Page 16 of 53

MHA STATUS: Section 2
MENTAL STATE: 1:1 with Simon who is preoccupied with his tribunal hearing. He was insisting that he is being framed
for something he did not do. He said he has his mother’s support. He denied being paranoid against his neighbours. He
insists he is innocent and has no mental illness. He has no insight. Reassurances and support offered by staff by
attempting to explain that he is being offered help, treatment for his condition and not being accused of any crime.
SOCIAL INCLUSION: Mostly on his computer in his room during the shift is INVESTIGATION: None carried out.

PHYSICAL HEALTH: He did not report any problem.
He ate and drank well.
MEDICATION: Not on regular medication.

PERSONAL CARE 6 ACTIVITIES: Is satisfactory, he interacted with fellow patients.
RISK AND OBSERVATION LEVEL: Of slow progress in his mental state.
To others on the ward is low.

On general observation.
LEAVE: Granted section 17 leave.
Has slept well. _______________________________________________________________________________________
Originator Details: 06 Nov 2018 17:42 Gifty Dadzie Nursing Originally Entered by Details:
06 Nov 2018 17:42 Gifty Dadzie Last Amended by Details: 06 Nov 2018 17:42 Gifty Dadzie
Validated by Details: 06 Nov 2018 17:42 Gifty Dadzie Significant: No Added to Risk History:
No
Contains Third Party Info: No Conceal from Client: Not Concealed MHA STATUS: On Section 2
MENTAL STATE: Simon has maintained a low profile. Remains relatively calm on the ward, though still lack insight into
his mental state. Seen interacting well with peers and staff. He utilised his leave on hospital ground.
SOCIAL INCLUSION: He utilised his section 17 leave and engaging with other peers.

MEDICATION: -
PHYSICAL HEALTH: Nil physical health concern.

INVESTIGATION: - Nil carried out today.
PERSONAL CARE & ACTIVITIES: He attending to his personal care.
RISK AND OBSERVATION: — Remains on general observation.

LEAVE STATUS: He utilised his unescorted section 17 leave. _________________________________________________
Originator Details: 06 Nov 2018 17:42 Gifty Dadzie Nursing Originally Entered by Details:
06 Nov 2018 17:43 Gifty Dadzie Last Amended by Details: 06 Nov 2018 17:43 Gifty Dadzie
Validated by Details: 06 Nov 2018 17:43 Gifty Dadzie Significant: No Added to Risk History:
No
Contains Third Party Info: No Conceal from Client: Not Concealed
Simon was seen by a solicitor today in preparation to his upcoming tribunal hearing. ___________________________
Originator Details: 06 Nov 2018 12:20 Maria Bruce Medical Originally Entered by Details:
06 Nov 2018 12:20 Maria Bruce Last Amended by Details: 04 Dec 2018 16:04 Maria Bruce Validated
by Details: 04 Dec 2018 16:04 Maria Bruce Significant: No Added to Risk History: No
Contains Third Party Info: No Conceal from Client: Not Concealed

https://rio.beh-mht.cse.thirdparty.nhs.uk/rio/Reports/RiOReports.asp 08/01/2019
16