Page 1560 - 6. 2016 Diary 1st half New 26-05-21 No Table

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

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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
Originator Details: 27 Aug 2016 05:55
Mary Doherty Nursing
Originally Entered by Details: 27 Aug 2016 06:07
Mary Doherty Last Amended by Details: 27 Aug 2016 06:07
Mary Doherty Validated by Details: 27 Aug 2016 06:07
Mary Doherty Significant: No Added to Risk
History: No
Contains Third Party Info: No Conceal
From Client: Not Concealed
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.

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