Page 1554 - 6. 2016 Diary 1st half New 26-05-21 No Table

Originator Details: 27 Aug 2016
Last Amended by Details: 27 Aug 2016
Neli Avramova Medical
Page Numbers: 39
40
ATSP, asking to self-discharge Hx and BG noted.
Handover from ward doctor received and advised that pt is not detainable unless
presentation massively changed. Simon is keen to be discharged today, he wants to visit
his civil partner, take his dog out for a walk and "get back to normal". He also intends to
go to AED for. CXR of his distal phalange of L small finger which he believes to be
broken following an accident on the ward - slipped in the bathroom. Advised by staff that
this was examined by duty doctor and it was felt it is unlikely to be a fracture. He admits
that he has benefited from his stay on the ward but feels that no further IP stay is
necessary as he would feel much more comfortable at home. He initially suggested to go
home today, stay overnight and return to the ward. The plan from the day team was for pt
to go out on escorted leave with staff and then gradually increase his leave and let him go
out alone. He refused going out with staff due to "embarrassment" of walking with staff if
he is seen by his neighbours/friends. I asked if he would be happy to be visited by HTT at
home on discharge and he agreed. He confirmed he is happy to take his meds and to
engage with HTT.
He denied any suicidal thoughts or thoughts of self-harm, denied thoughts of harming
others. Denied any hallucinatory experiences.
MSE
Looks kempt, good eye contact, rapport established Speech - normal rate, tone, volume,
coherent Mood - euthymic, reactive affect
Thoughts - no formal thought disorder, no thoughts of harming self/others, no delusional
beliefs, forward looking Perception - denied hallucinations, not responding to unseen
stimuli
Risks:
Risk of harm to self - low Risk of harm to others – low Risk of meds noncompliance and
non-engagement with services- however pt confirms he will engage with HTT and take
his meds and is not detainable
Plan
discharge with HTT follow up - NS to kindly arrange HTT referral Px 2 weeks TTA

8
• The Doctor’s Folder / pub Book Issue: 5!
Stage 5
Folder 5
Originator Details: 27 Aug 2016
Last Amended by Details: 27 Aug 2016
Mary Doherty
Page Numbers: 40
CP1; Simon was in his room using his computer when the shift began, only coming out
to attend to his needs. He appears pleasant and calm and interacting well with staff and
peers alike.
CP2; He had his night drink.
CP5; He complied with his prescribed night medication. He had a good night sleep and
remains asleep at the time of writing this report.