Day 10 Case Notes Analysis

This case notes will be used for writing today’s letters for correction. Before you proceed to writing this letter on the writing page, please read this case notes and answer the questions that below:



Read the case notes below and complete the writing task which follows.


You are a nurse with the Modbury Home Nursing Centre. You visited this patient at home today for the first time following a referral from the Modbury Hospital. He was discharged from hospital on 03/06/2020.

Name: Oliver Garfield
Address: 80 Blue Street, Mount Calvary 4121
Phone: (07) 3931 2877
Date of Birth: 2 February 1937
Admitted: 01/06/2020
Diagnosis: Malignant Melanoma, L Shoulder

Medical History

Large lesion successfully removed 01/06/2020.
Needs assistance with showering, dress wound, prior removal of sutures at Modbury Hospital  (14/06/2020)

Family History

Married aged pensioner. In housing commission home. He, wife Ruth (aged pensioner).
A son and daughter (settled abroad. Last visited 4 years ago)


Showered. Wound dressed (healing satisfactory, nil infection. Balance little shaky. Complaining increased arthritic pains in hands, legs.

Currently taking:

  • Glucosamine & Chondroitin Supplement (recommended by GP).
  • Pain relieved 2 Panadol 3 times daily.

Confused (why he had operation!)
Ruth concerned. “I will be 83 in August. Oliver has not been himself since the surgery.”

Keeps forgetting. Managing house and garden tough job. Neighbours help shopping.
Disordered kitchen, bathroom – trouble finding clean towels – dishes piled in sink, bed unmade.


Mr Oliver showered and wound dressed. Still a little unbalanced. Rests most of the day. Does not remember being showered yesterday. House still disorganized, washing piled up in bathroom. Ruth says she would be lost without help from neighbours who also appear to be cooking meals for the couple.

Concerns: Provided there are no complications with the wound healing, your role in providing nursing care ends when sutures are removed on 14th of this month. You consider that Jim and Ruth need to be assessed for further on-going assistance in managing the house and garden and with shopping and the preparation of cooking.


Request a home visit by the Aged Care Assessment Team as soon as possible to fully assess their needs and to arrange for appropriate further assistance to be provided.

Writing Task

Using the information in the case notes, write a letter to The Director, Aged Care Assessment Team, Brisbane South Region, 78 Masterson St. Acacia Ridge, Brisbane 4110. Explain why you are writing and what types of assistance may be required.

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.

Now take this Case Notes Analysis and proceed to Letter Writing

  • Question of

    What is the purpose of writing this letter?

    • Requesting further treatment
    • Requesting home care
    • Requesting home visit
    • Transfer
  • Question of

    Who is the recipient of this letter?

    • Doctor
    • Carer
    • Family members
    • Aged Care Assessment Team
  • Question of

    Are there more than 1 patient in the case notes?

    • Yes
    • No
  • Question of

    Who is the primary patient?

    • Mr Oliver
    • Ms Ruth
  • Question of

    What is not a relevant information?

    • About son and daughter
    • About washing
    • About help by neighbors
    • None
  • Question of

    What is the admission / discharge status?

    • Admitted
    • Will be discharged today
    • Admitted and discharged
    • Discharge not yet planned

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  1. 05 June,2020

    The Director
    Aged Care Assessment Team
    Brisbane South Region
    78 Masterson Street
    Acacia Ridge
    Brisbane 4110

    Dear Sir/Madam,

    Re : Mr Oliver Garfield,83 years

    I am writing to request an urgent home visit for Mr Garfield and his wife Mrs Ruth as the former has been recovering from malignant melanoma of the left shoulder.They require your further assessment and assistance in activities for daily living.

    Mr Garfield was admitted on the 01 st of this month for removal of a large malignant lesion on his left shoulder and discharged home two days later with the arrangement of regular home visits.

    During Mr Garfield’s initial home visit yesterday,Mrs Ruth was worried about managing home and garden due to her old age.She also reported changes in Mr Garfield’s mental status following surgery. Although she is getting help from her neighbours for shopping and cooking,she faces difficulty to perform daily household activities effectively.

    Currently,his wound is healing well without any complications. However,he has an unsteady gait and memory loss.I have been concerned about the general health of this old couple because my care will be finished on 24 th of this month.

    In view of the above information,it would be greatly appreciated if you could visit this elderly couple and provide necessary assistance in shopping and meal preparation.Please note,they reside at 80 Blue Street,Mount Calvary 4121.

    If you have any queries,please contact me.

    Yours faithfully,

    Registered Nurse

  2. 05 June 2020

    The Director
    Aged Care Assessment Team
    Brisbane South Region
    78 Masterson St
    Acacia Ridge
    Brisbane 4110

    Re: Mr Oliver Garfield, DOB: 02 February 1937

    Dear Sir/Madam

Written by Biju John

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Day 9 Speaking Tasks

Day 10 Speaking Tasks