Page 1432 - 6. 2016 Diary 1st half New 26-05-21 No Table

-Previous notes state that Simon has Crohn's according to his mother. Simon denied this and
is not currently seeing anyone for this and is not taking any medication -Denied any other
physical health problems
-Simon was not fully examined as he was becoming increasingly aroused through the
interview -Obs noted to be NAD on admission -GCS 15/15
-Mobilising independently, normal gait
Risk Summary:
-to self: denied any thoughts of self-harm or suicide -to others: denied any thoughts to harm
others
-from others: vulnerable when unwell - need to explore whether he is being financially
independent.
-disengagement: highly likely to disengage
-Substance misuse: denied using drugs, cigarettes or alcohol
Plan:
1. Admit under Section 2 of MHA
2. 15 min obs
3. UDS to be done please
4. Physical and bloods to be done by day team please
Medication chart written

9
The Doctor’s Folder / pub Book Issue: 5!
Stage 5
Folder 5
Originator Details: 15 Aug 2016
Last Amended by Details: 15 Aug 2016
Teeresh Bundhun
Page Numbers:67
Originator Details: 15 Aug 2016 19:47
Teeresh Bundhun Nursing
Originally Entered by Details: 15 Aug 2016 19:51
Teeresh Bundhun Last Amended by Details: 15 Aug 2016 19:51
Teeresh Bundhun Validated by Details: 15 Aug 2016 19:51
Teeresh Bundhun Significant: No Added to Risk
History: No
Contains Third Party Info: No Conceal
From Client: Not Concealed
Bed Manager
I received a Tc from Cygnet Stevenage (Susan) who informed that they are still looking at the
referral for Simon.

10
The Doctor’s Folder / pub Book Issue: 5!
Stage 5
Folder 5
Originator Details: 15 Aug 2016
Last Amended by Details: 15 Aug 2016
Teeresh Bundhun
Page Numbers:67
Originator Details: 15 Aug 2016 18:13