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Progress Notes Page 22 of 53

Originator Details: 04 Nov 2018 18:22 Ralph Antwi Nursing Originally
Entered By Details: 04 Nov 2018 18:31 Ralph Antwi Last Amended By Details:
04 Nov 2018 18:31 Ralph Antwi Validated By Details: 04 Nov 2018 18:31 Ralph
Antwi Significant: No Added to Risk History: No
Contains Third Party Info: No Conceal From Client: Not Concealed MHA
STATUS: Sec 2
MENTAL STATE: Appeared reasonably stable in his mental state.

SOCIAL INCLUSION: Mostly on computer in his bed area during the shift, observed interacting with his peers.
INVESTIGATION: None carried out

PHYSICAL HEALTH : Nil reported or observed during this shift, eating and drinking very well.
MEDICATION: Not on regular medication.
PERSONAL CARE & ACTIVITIES: Satisfactory, did not participate on ward activities.

RISK AND OBSERVATION LEVEL: Nil, on general observation.
LEAVE: On section 17 leave. ____________________________________________________________________________
Originator Details: 04 Nov 2018 05:46 Robert Nnubia Nursing Originally Entered By Details:
04 Nov 2018 05:46 Robert Nnubia Last Amended By Details: 04 Nov 2018 05:46 Robert Nnubia
Validated By Details: 04 Nov 2018 05:46 Robert Nnubia Significant: No Added to Risk History:
No
Contains Third Party Info: No Conceal From Client: Not Concealed MHA Status: Sec 2
Mental State: Presented as polite, calm and stable in mental state on the shift. He was observed to be keeping to self
in his bed space watching tv during most part of the shift. No paranoid ideas expressed on the shift

Social Inclusion: Minimal interaction on the ward, however pleasant on approach
Investigation: Nil on the shift
Physical Health: Nil complained or observed on the shift. Had hot drink and snack and retired to bed and appears to
have slept well.
Medication: He is not on any prescribed medication
Personal Care and Activities: Appears satisfactory and did not participate in any ward base activity

Risk and observation Level: Nil observed to self or others on the shift. He is nursed on general observations.
Leave Status: He did not utilised his sec 17 leave on the shift ______________________________________________
Originator Details: 03 Nov 2018 17:34 Gladys Osunsina Nursing Originally Entered By Details:
03 Nov 2018 17:45 Gladys Osunsina Last Amended By Details: 03 Nov 2018 17:45 Gladys Osunsina
Validated By Details: (UNVALIDATED)
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
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