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Progress Notes Page 23 of 53

Mental state-- Simon appeared calm, pleasant and stable during the shift.
Mental status - On section 2 of the MHA of 1983 Social inclusion- Mostly in
his room but coming out occasionally Medications- Not on any medication at

the moment Physical Health- No physical symptoms complained of and non
observed. Observation and Risk assessment - Nursed on general level of

observation Leave status- Did no utilize his unescorted section 17 leave
today.

Originator Details: 03 Nov 2018 07:16 Lawrence Giwa Nursing Originally Entered By Details:
03 Nov 2018 07:24 Lawrence Giwa Last Amended By Details: 03 Nov 2018 07:24 Lawrence Giwa
Validated By Details: 03 Nov 2018 07:24 Lawrence Giwa Significant: No Added to Risk History:
No
Contains Third Party Info: No Conceal From Client: Not Concealed MHA STATUS: Sec 2
MENTAL STATE: Appears fairly calm in mood and presented as stable in metal state on the shift. Observed sitting in
the lounge area with peers watching tv for a while.
SOCIAL INCLUSION: Interacting well on the ward with service user and staff

INVESTIGATION: None carried out
PHYSICAL HEALTH : Nil reported or observed during this shift MEDICATION: He was not any medication on this
shift

PERSONAL CARE & ACTIVITIES: Appears satisfactory. Hence no ward based activities by the OT on this shift
RISK AND OBSERVATION LEVEL: Nil observed or reported to self or others on the shift. He was nursed on general
observation.
LEAVE: No sec 17 leave at the moment_________________________________________________________________
Originator Details: 02 Nov 2018 17:39 Gladys Osunsina Nursing Originally Entered By Details:
02 Nov 2018 17:42 Gladys Osunsina Last Amended By Details: 03 Nov 2018 17:46 Gladys Osunsina
Validated By Details: 03 Nov 2018 17:46 Gladys Osunsina Significant: No Added to Risk
History: No
Contains Third Party Info: No Conceal From Client: Not Concealed Simon appears relatively settled
on the ward but has no clear insight into his mental state. He is not on any medication at the moment. Went to utilize
his unescorted section 17 leave and came back to the ward with no management problem.____________________
Originator Details: 02 Nov 2018 10:00 Maria Bruce Medical Originally Entered By Details:
05 Nov 2018 11:17 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

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