Booklet 01

Case Notes – Jim McDonald’s




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

Today’s Date: 23/3/22

You are a nurse with the Blue Skies Home Nursing Centre. You visited this patient at home today for the first time following a referral from the Spirit Public Hospital. He was discharged from hospital on 17/03/22 and was visited by another nurse on 22nd March.


  • Patient Name: Jim McDonald’s
  • Address: 12 Deep Quarry Pit, South Valley, Brisbane, 4121
  • Phone: (07) 3941 2267
  • Date of Birth: 2 February 1949
  • Admitted: 14/3/22
  • Diagnosis: Malignant Melanoma Left Shoulder

Medical History

  • Large lesion successfully removed 14/3/22
  • Discharged 17/3/22
  • Needs assistance with showering and to dress wound prior to removal of sutures at Mater Public Hospital on 28/3/22

Family History

  • Married aged pensioner.
  • Lives in housing commission home with wife Dorothy also an aged pensioner.
  • No children

22/3/22 – 1st Home visit

  • Showered patient.
  • Wound dressed – healing satisfactory
  • No sign of infection
  • Balance a little shaky
  • Complaining of increased arthritic pains in hands and legs.
  • Currently taking Glucosamine & Chondroitin Supplement recommended by GP.
  • Pain relieved with 2 Panadol 3 times daily.
  • Confused about why he had operation.
  • Dorothy concerned about future. Tells she will be 83 in August.
  • Says Jim has not been himself since the surgery.
  • Keeps forgetting things. She finds it difficult to manage the house and garden.
  • Neighbours are helping with shopping.
  • Kitchen and bathroom disordered – trouble finding clean towels – dishes piled in sink, bed unmade.


  • Jim 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.
  • Dorothy says she would be lost without help from neighbors who also appear to be cooking meals for the couple.
  • Concerns: Provided there are not complications with the wound healing, your role in providing nursing care ends when sutures are removed on 24 March.
  • You consider that Jim and Dorothy 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.


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.