Case Notes 46 Nursing

Occupational English Test – Writing (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.

Details to Fill In:

• CANDIDATE NAME. ROLE NUMBER.
• DATE OF BIRTH. VENUE OF THE TEST. TEST DATE.

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

Notes:

This patient has been visiting the school’s Mental Health Centre and you are her charge nurse at St. Mary’s Primary School. She will be moving to Adelaide next month to continue her studies.

Today’s Date: 24 July, 2024

Patient History:

• Name: Eva Gingerades.
• DOB: 15.08.2013.
• Parents: Mr and Mrs Gingerades. 3434 Blithe Street, Charity Circle, Perth.

24 June, 2024

Subjective:

• Reports difficulty coping with other students.
• Complains of frequent feelings of anxiety and isolation.
• No significant family history of psychiatric issues.
• Non-smoker, does not consume alcohol or caffeine.
• Current Medication: None

Objective:

• BP: 110/70; P: 72 regular
• Height: 145 cm; Weight: 40 kg
• Physical examination: Normal
• Mental health screening: Indications of social anxiety and mild depression.

Plan:

• Referred to school counsellor for weekly sessions.
• Advised to keep a daily journal of her feelings and social interactions.
• Recommended to participate in group activities to improve social skills.
• Review in 4 weeks to assess progress.

14 July, 2024

Subjective:

• Reports slight improvement, but still feels anxious around peers.
• Parents note she has been more withdrawn at home.

Objective:

• BP: 108/68; P: 70 regular
• Assessment: Continue with school counsellor sessions. Initiate referral to a child psychiatrist for further evaluation and potential therapy in Adelaide.

24 July, 2024

Subjective:

• Mixed progress: occasional positive social interactions but persistent anxiety.
• Parents express concern about her transition to a new school in Adelaide.
• Objective: BP: 110/70; P: 72 regular.

Plan:

• Immediate referral to Dr. Sarah Thompson in Adelaide for comprehensive evaluation and therapy.
• Continue weekly counselling sessions with a school counsellor until relocation.
• Engage parents in supportive strategies at home (until relocation), including positive reinforcement and structured routines. Consider continuation in Adelaide.
• Consider need for medication. ? Therapy alone does not yield improvement.
• Coordinate with the new school in Adelaide to implement a support system for her transition, including a peer buddy system and regular check-ins with the school nurse or counsellor.
• Schedule a follow-up appointment in < 1 month of relocation. Purpose: Review adaptation, progress with Dr. Thompson.
• Encourage participation in extracurricular activities. Objectives: Enhance social skills, reduce feelings of isolation.

Writing Task

Write a letter addressed to Dr. Sarah Thompson, Psychiatrist, 567 North Terrace, Adelaide SA 5000, describing the situation.

In your answer:

• Expand the relevant notes into complete sentences (Do not use note form).
• Eliminate irrelevant details.
• Follow the MELONS Organization (Meeting, Enquiry, Listening, Offering, Neutralization, Summarization).
• Punctuate appropriately with small and capital letters, full stops, and commas.
• Use correct grammar. Insert “the” before body parts/organs.
• Use letter format.

The body of the letter should be approximately 180–200 words. Do not pick up your pen during the 5 minutes of reading time.

Melons Steps

• Mark (M) PPRRAADDDDDWK.
• Eliminate (E) irrelevant information.
• Launch (L) the letter with DADR.
• Open (O) the letter with PRPDD or PRPTT.
• Narrate (N) the remaining paragraphs using V or W.
• Sign (S) the letter with S/F.

Melons Errors

• Punctuation “Marks”.
• Follow “Expansion” Rules.
• Obey “Language” Rules.
• Have an “Order” (DADR, PRPDD, V/W, S/F)
• Do not change “Names”.
• Sex (Mr, Ms, Mrs, His, Her).