Occupational English Test – Writing case Notes | Nursing
Instructions:
- You have 45 minutes to write this letter.
- During the first 5 minutes, you should not pick the pencil.
- Start writing only when you are told.
- During the Reading Time, try to understand the case notes.
Read the case notes below and complete the writing task which follows.
Notes:
Mr Carry Milton is a 71-year-old patient on the ward of a hospital in which you are Charge Nurse.
Patient Details
- Marital Status: Single.
- Admission Date: 02 March, 2024.
- Discharge Date: 06 March, 2024.
- Diagnosis: Right Hip Fracture.
Social Background:
- Lives alone. Employed, civil engineer (retirement 65 years). Pensioner.
- Cousin Mr Pethian – supportive – visits regularly.
- Ambulatory: Use of a cane.
Medical Background:
- 2012 – Hypertension (ongoing management).
- 1988 – Colle’s fracture, ORIF.
- 1986 – Appendicitis – operated.
- Medication: Ramipril 5 mg., OD.
02 March, 2024
- Brought to emergency department after slipping on ice.
- Reports right hip pain; inability to bear weight.
- Physical examination of the right leg – positive log roll test and pain with range of motion.
- X-ray – displaced sub-capital femoral neck fracture of the right hip.
- Surgery – unipolar hemiarthroplasty.
03 March, 2024
- Hemodynamically stable.
- Physiotherapy therapy started.
- Weight-bearing exercises as tolerated.
- Medications: low-molecular-weight heparin and analgesics.
- Nutritional supplements – surgery to improve protein levels and caloric intake
05 March, 2024
- Tolerates physiotherapy.
- Improvement in mobilization.
- Able to walk short distances with walker
06 March, 2024
- Interdisciplinary care program – discharge planning, rehabilitation, and posthospital services.
- Progress discussed with cousin.
- Wishes to continue physiotherapy at home.
- Wound dressing done. No SSI.
Discharge Plan
- Preserve skin integrity.
- Continue exercise program.
- Continue: Wound monitoring.
- Education: Importance of physiotherapy and good nutrition.
- Report: Complications.
- Follow up: After 3 weeks
Writing Task
Using the information given in the case notes, write a letter Mr Milton’s GP, Dr March Highland, Colossal hospital, Brisbane, Australia. In your letter, briefly outline the patient’s clinical condition and progress.
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. However, you needn’t include any irrelevant information to reach the word-count; nor do you have to omit any information to avoid exceedance.
