OET WritingBeryl Casey

Notes:
Patient: Mrs Beryl Casey (DOB: 21/11/1941) is a 72-year-old woman who is being
discharged from hospital to a rehabilitation centre.
Marital status: Widowed (recently)
Family: 2 children – son lives locally & daughter interstate.
Social: Lives alone in 2-bedroom house with stairs to entrance. Son (married, 2
children – 6 & 8) lives 20 minutes away – visits twice a week. Enjoys gardening.
Medications: Anti-hypertensive (Ramipril) 10mg
Admission date: 4/02/14 at 1200hrs
Fainted getting out of bed & fell to the floor. Found by son 2 hours later.
Diagnosis: X-ray – fractured left neck of femur (# L NOF) post fall
Treatment: Left hemiarthroplasty (Austin Moore hip replacement); general

anaesthesia Incision closed with staples & 2x Exudrain
Post operation:
 Intravenous (IV) therapy: 3 units packed cells – with IV Lasix (furosemide)

40mg therapy after each unit (intraoperative & post op) Maintained IV therapy
for 36hrs, then ceased and oral fluids encouraged Intravenous antibiotics
(IVABs) – Cephazolin 1g t.d.s. for 3/7 – course completed
 Vital signs: BP hypotensive – 95/60, other obs. within normal limits Anti-
hypertensive medication reviewd by Dr – Dose  now Ramipril 5mg daily
 Pain management: Patient-controlled analgesia (PCA) with Fentanyl for 36hrs –
pain relief – satisfactory. Commenced oral analgesia 36hrs post op  Panadeine
or Panadol 4/24 prn, Max 4 doses/24hrs
 Wound management: Dressing √ Total of 600mlhaemoserous
fluid discharge from Exudrains over 24hrs Drain tubes removed
48hrs post op (Day 2) Alternate staples removed Day 5 and dressing changed
Mobility & activities of daily living (ADLs):
 Day 2 Sitting out of bed (SOOB) short periods, full assistance

 Day 3 Mobilising with pick-up frame (PUF) & 2-person assist
 Day 4 Uneventful
 Day 5 Mobilising short distances with PUF & 1-person assist Abduction
pillow when resting in bed (RIB) Anti-embolic stockings in situ for 14 days
ADLs – full assistance
 Day 6 Uneventful day Preparing for discharge
Discharge plan:
 Day 7 (1100hrs) Discharge to the Rehabilitation Centre Discharge medications –

Ramipril 5mg daily, paracetamol 1g qid prn Family to be
notified of transfer Hospital transport arranged for 1100hrs
 Day 8 Repeat check of hemoglobin (Hb) levels Monitor BP b.d., for 3/7, due
to adjustment in anti-hypertensive meds Assess for rehab therapy (inpatient & on
return home)
 Day 10 Removal of remaining staples, wound can remain exposed afterwards
Writing Task:
Using the information given in the case notes, write a discharge letter to the Nursing
Unit Manager, The Rehabilitation Centre, Waterford.
In your answer:
• Expand the relevant notes into complete sentences
• Do not use note form
• Use letter format
The body of the letter should be approximately 180–200

words.
MODEL ANSWER
Nursing Unit Manager
The Rehabilitation Centre
Waterford
10 February 2014
Dear Nursing Manager,
Re: Mrs Beryl Casey, 72-year-old widow
On 4 February 2014, Mrs Casey fainted getting out of bed and fell. She was admitted to
hospital with a fracture of the left neck of femur. She underwent emergency orthopaedic
surgery for a left hemiarthroplasty (Austin Moore hip replacement) under general
anaesthetic.
Normally, Mrs Casey’s hypertension is treated with Ramipril 10mg daily. Post-
operatively, she was hypotensive so Ramipril was reduced to 5mg daily. Her blood
pressure needs monitoring twice a day for three days. Post-operatively, she received 3
units of packed cells, so requires a repeat check of haemoglobin on Day 8. Wound drain
tubes were removed on Day 2. Alternate staples were removed on Day 5 and the wound
dressing remains dry and intact.
The remaining staples are for removal on Day 10 and the wound can remain exposed.
She now uses Panadol or Panadeine 4 hourly as needed to manage pain.
Mrs Casey is mobilising with a pick-up frame and one assistant. She uses an abduction
pillow when in bed and her anti-embolic stockings should remain on until Day 14.
Assistance is required with all daily activities.
Mrs Casey requires assessment for rehabilitation therapy prior to returning home.
If you have any questions, please contact me.
Yours sincerely,
Nurse in charge
SAMPLE RESPONSE: LETTER OF DISCHARGE
1. Nursing Unit Manager

The Rehabilitation Centre
Waterford
10 February 2014
Dear Nursing Manager,

Re: Mrs Beryl Casey, 72-year-old widow
On 4 February 2014, Mrs Casey fainted getting out of bed and fell. She was admitted to
hospital with a fracture of the left neck of femur. She underwent emergency orthopaedic
surgery for a left hemiarthroplasty (Austin Moore hip replacement) under general
anaesthetic.
Normally, Mrs Casey’s hypertension is treated with Ramipril 10mg daily. Post-
operatively, she was hypotensive so Ramipril was reduced to 5mg daily. Her blood
pressure needs monitoring twice a day for three days. Post-operatively, she received 3
units of packed cells, so requires a repeat check of haemoglobin on Day 8. Wound drain
tubes were removed on Day 2. Alternate staples were removed on Day 5 and the wound
dressing remains dry and intact.
The remaining staples are for removal on Day 10 and the wound can remain exposed.
She now uses Panadol or Panadeine 4 ho urly as needed to manage pain.
Mrs Casey is mobilising with a pick-up frame and one assistant. She uses an abduction
pillow when in bed and her anti-embolic stockings should remain on until Day 14.
Assistance is required with all daily activities.
Mrs Casey requires assessment for rehabilitation therapy prior to returning home.
If you have any questions, please contact me.

Yours sincerely,
Nurse in charge
2. Writing Candidate Answer 2
9 February 2014
Nursing Unit Manager
The Rehabilitation Centre,
Waterford
Dear Sir or Madam
Re: Mrs. Beryl Casey (DOB: 21 November, 1941)
Mrs Casey (Widowed recently), who has been treated for a fractured her left neck of
femur, as she fainted and fell to the floor, is being discharged tomorrow. Therefore she
is being referred to you for following up care.
Mrs Casey - lives alone - was found by her son who lives close to her home 2 hours
later and admitted to our hospital on 4 February, 2014.
Mrs Casey had a left hemiarthroplasty and closed with staples and 2 exudrain tubes.
After the operation, she has completed the intravenous antibiotics, also the drain tubes
and alternate staples has removed. In addition, her pain has controlled by medication
and her blood pressure has remained by Ramipril 5 mg (previously used 10 mg).
Furthermore, she is able to walk with a pick-up frame and an assistant person, although
she needs full assistance with her ADL.
It would be greatly appreciated if you could continue maintaining her medication and
monitoring her blood pressure. Also, please assess for her rehabilitation therapy. In
addition, she will require to check her haemoglobin levels on 11/2/14 and remove
remaining staple on 13/2/14. Finally, a hospital transport has arranged for 11 o’clock
tomorrow morning.
If you need further question, please do not hesitate to contact me.
Kind regards,
Charge Nurse

OET WritingBeryl Casey

Uploaded by

Copyright:

Available Formats

OET WritingBeryl Casey

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

OET WritingBeryl Casey

Uploaded by

Copyright:

Available Formats

Notes:

Marital status: Widowed (recently)

Family: 2 children – son lives locally & daughter interstate.

Medications: Anti-hypertensive (Ramipril) 10mg

Admission date: 4/02/14 at 1200hrs

Diagnosis: X-ray – fractured left neck of femur (# L NOF) post fall

Treatment: Left hemiarthroplasty (Austin Moore hip replacement); general

 Intravenous (IV) therapy: 3 units packed cells – with IV Lasix (furosemide)

Mobility & activities of daily living (ADLs):

 Day 2 Sitting out of bed (SOOB) short periods, full assistance

 Day 7 (1100hrs) Discharge to the Rehabilitation Centre Discharge medications –

• Expand the relevant notes into complete sentences

• Do not use note form

• Use letter format

The body of the letter should be approximately 180–200

Nursing Unit Manager

The Rehabilitation Centre

Dear Nursing Manager,

Re: Mrs Beryl Casey, 72-year-old widow

If you have any questions, please contact me.

1. Nursing Unit Manager

Dear Nursing Manager,

If you have any questions, please contact me.

Dear Sir or Madam

Re: Mrs. Beryl Casey (DOB: 21 November, 1941)

If you need further question, please do not hesitate to contact me.

You might also like

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.