Case Notes 55.1 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.

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).

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

Notes:

Today’s Date: 10/08/2024

Hospital: Pine Hill Hospital, Brisbane.

Patient Details:

• Name: Ingrid Larson.
• Age: 72 years.
• Address: 23 5^th Avenue, Pine Country, Brisbane.
• Marital Status: Married
• Admission Date: 01/08/2024.
• Discharge Date: 10/08/2024
• Diagnosis: Fractured hip

Medical History

• Anxiety disorder (diagnosed 2019).

Social, Economic, Psychological Background:

• Lives in: Highgate, Owns house.
• Income: Retired librarian.
• Primary Caregiver: Husband (Daniel)
• Financial Situation: Moderate
• Socialization: Active community member

Admission Details:

• Fell in garden, hip fracture.
• Bruising and abrasions
• Blood loss: Mild, no transfusion needed.
• Surgery: Hip replacement done on 02/08/2024

Treatment and Progress:

• 03/08/2024: Stable, mild pain (3/10), prescribed ibuprofen 400 mg.
• 05/08/2024: Mild fever, paracetamol 500 mg administered, pain manageable.
• 06/08/2024: Fever resolved, started on physiotherapy, and occupational therapy.
• 09/08/2024: Preparing for discharge, wound clean and dry, no signs of infection

Plan:

• Social Worker Referral: For assistance and service continuation at home.
• Home Modifications: Installation of handrails, bathroom modifications.
• Aid Required: Walking frame, shower chair (not yet arranged).
• Therapy: Continue physiotherapy and occupational therapy.
• Wound Care: Daily dressing by community nurse (arranged).
• Follow-Up: After 10 days (to be scheduled).
• Support: Connect to local senior support groups (not arranged).

Writing Task

Using the information in the case notes, write a referral letter to Mr. David Cooper, social worker, Adams Street, Highgate, Brisbane.

In your answer:

• Expand the relevant notes into complete sentences (Do not use note form).
• Eliminate irrelevant details.
• Follow the MELONS Organization. Follow DADR, PRPDD / TT, V/W and S/F.
• Punctuate appropriately with small and capital letters, full-stops, 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 your pencil during the 5 minutes of reading time.