22/05/2012
22:00
Inpatient –
Nursing
Title:Night shift
Li has been nursed on intermittent observations this shift. He asked to go to bed as soon as night
staff came on this evening and so went to bed at 21.00. He setled to bed and appeared asleep by
22.00 and woke once in the night to use the bathroom, however there is a strong smell of urine in
his room, suggesting that he may have been incontinent overnight. Sheets to be checked when
he wakes up.
He has slept throughout the night. – —————————- Confirmed By LNorman@
22/05/2012
19:30
Inpatient –
Nursing
Title:Late shift
Li was nursed on intermittent observations. Li appeared in a bright mood at the start of the shift he
went for a walk with staff and peers this afternoon which he reported that he enjoyed. Li has
interacted well with his peers and has spent time watching TV. This evening the pat dog visited
the ward and Li kept his distance as he is not keen on dogs but managed the situation well. – —————————- Confirmed By GRodda@
22/05/2012
19:00
Occupational
Therapy
Title: Pets as Therapy Session
Li agreed to attend session and stayed for duration. He reported he wanted to continue getting
used to the PAT dog. He appeared to be in a good mood this evening and engaged well with staff
and peers. Li came out into the patio of his own volition and gradually was able to approach the
PAT dog and stand closer. He agreed to come on a walk with the dog and appeared very
motivated to do this. Li was able to talk with owner of the dog appropriately. Li was able to take
the lead of the dog and walk her when prompted by staff and he managed this well.
Li was praised for managing this evenings session well.
– ————————— 23 May 2012 08:51, Joanna Loomes
Event By: Joanna Loomes
22/05/2012
16:00
Inpatient –
Ward Round
Title:Ward Round Feedback
Ward Round Plan:
– Care plan for ‘active listening’ to be made by RChapman in case of disclosures following
upcoming psychological work. – Oliver to discuss self-harm at night and discuss care plan to allow him to go to bed early, on the
basis that any self harming will negate this. – Full risk to be done by doctors. – No leave. – CPA arranged for 27/06/12.
Spoke to foster carer, Mr Thompson, and gave ward round feedback. He was happy with the
progress that Li is making. Mr Thompson agreed to update social worker. – —————————- Confirmed By CMcKenzie@, 22/05/2012
22/05/2012
13:45
Occupational
Therapy
Title: Group Namne: Circus Skills
OT Intervention: Creative Expression
Li attended this session but decided to leave after approximately 30 minutes reporting it to be “too
hot”. During his time in the group Li appeared to be of positive moood and interacted well with
both staff and peers. Li was able to maintain concentration throughout his time in the group. – ————————— 22 May 2012 14:29, Chris Snipp
Event By: Chris Snipp
22/05/2012
10:00
Inpatient –
Ward Round
Title:Ward Review – MDT
Attendees:
Dr H. Garrett, Dr Z. Soomro, E. Marlow, Mrs J Coles, R. Banton, S. Calver, L. Guard (OT), R.
Chapman, C. Mckenzie.
Diagnostic Clarity
Assessment of Risk
Some bedwetting but no blood found on bed, Section2 has been rescinded, foster parents
expressed their concerns regarding this.
Engaging with Oliver Sindall.
Has just started opening up about his abuse, if he continues in this vein will need to set up a plan
and boundaries in-case of likelihood of him getting really distressed and aggressive.
Plan:
R. Chapman will do a care plan of active listening opposed to leading questions.
Full risk assessment needs to be completed by Doctor.
CPA on 27/06/2012
Helen Wilde to talk to parents in-case of support, if she couldn’t then Ragnhild would talk to them.
– —————————- Confirmed By ZSoomro@ 28/05/2012
22/05/2012
07:30
Inpatient –
Nursing
Title:Early shift
Li appears to be bright in mood interacting and engaging well with peers. He join in groups
session and also went to education with some prompting.
No emotional distress reported and observed. – —————————- Confirmed By OOgunode@s, 22/05/2012
22/05/2012
06:24
Inpatient –
Nursing
Title:Night shift
Li was already in bed asleep at the beginning of the shift and observed to have slept throughout
the night. No management issue. – —————————- Confirmed By TDohmatob@, 22/05/2012
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