OET Discharge Writing Sample 1
Read the case notes and complete the writing task which follows.
Assume that today's date is 10 February 2019
Mr Lionel Ramamurthy, a 63-year-old, is a patient in the medical ward of which you are
Charge Nurse.
Hospital: Newtown Public Hospital, 41 Main Street, Newtown
PATIENT DETAILS:
Name: Lionel Ramamurthy (Mr)
Marital status: Widowed – spouse dec. 6 mths
Residence: Community Retirement Home, Newtown
Next of kin: Jake, engineer (37, married, 3 children <10)
Sean, teacher (30, married, working overseas, 1 infant)
Admission date: 04 Feb 2019
Discharge date: 11 Feb 2019
Diagnosis: Pneumonia
PAST MEDICAL HISTORY:
Osteoarthritis (mainly fingers) – Voltaren (diclofenac)
Eyesight Ô due to cataracts removed 16 mths ago – needs check-up
Social background:
Retired school teacher (history, maths). Financially independent. Lonely since wife died.
Weight loss approx. 4 kg in 6 months – associated with poor diet.
Medical history: 2007: Type 2 diabetes diagnosed (controlled by diet)
04 Mar 2018 Chronic obstructive pulmonary disease (COPD) diagnosed
MEDICAL BACKGROUND:
Admitted with pneumonia – acute shortness of breath (SOB), inspiratory and expiratory
wheezing, persistent cough ( Ò chest & abdominal pain), fever, rigors, sleeplessness,
generalised ache. On admission – mobilising with pick-up frame, assist with ADLs (e.g.,
showering, dressing, etc.), very weak, ambulating only short distances with increasing
shortness of breath on exertion (SOBOE).
MEDICAL PROGRESS:
Afebrile.
Inflammatory markers back to normal.
Slow but independent walk & shower/toilet.
Dry cough, some chest & abdom. pain.
Weight gain (1.5kg) post r/v by dietitian.
NURSING MANAGEMENT:
Encourage oral fluids, proper nutrition.
Ambulant as per physio r/v.
Encourage chest physio (deep breathing & coughing exercises).
Sitting preferred to lying down to ensure postural drainage.
Assessment: Good progress overall
Discharge plan: Paracetamol if necessary for chest/abdom. pain.
Keep warm.
Good nutrition – Ó fluids, eggs, fruit, veg (needs help monitoring diet).
WRITING TASK:
Using the information given in the case notes, write a discharge letter to Ms Georgine
Ponsford, Resident Community Nurse at the Community Retirement Home, 103 Light
Street, Newtown. This letter will accompany Mr Ramamurthy back to the retirement
home upon his discharge tomorrow.
Sample Response
Ms Georgine Ponsford
Resident Community Nurse
Community Retirement Home
103 Light Street
Newtown
10 February 2019
Dear Ms Ponsford,
Re: Lionel Ramamurthy, aged 63
Mr Lionel Ramamurthy was admitted on 4 February 2019 having contracted pneumonia.
He is now ready for discharge back into your care tomorrow.
On admission, he was experiencing fevers and rigors. He suffered dyspnoea, wheezing
and sleeplessness. He had chest and abdominal pain due to prolonged persistent
coughing.
After a week in hospital, he has stabilised and his breathing problems are now resolved.
However, he still experiences some chest and abdominal pain, with a dry cough. His
nursing management in hospital initially consisted of a walking frame and assistance
with showering and dressing. Mr Ramamurthy is now more independent. He is also able
to walk about slowly without assistance, and shower and use the toilet independently.
Paracetamol may be administered as needed if chest and abdominal pain persists and
Mr Ramamurthy should be kept warm. Please encourage oral fluids, and ensure that he
sits up, rather than lies down, whenever possible to ensure postural drainage. He
should ambulate regularly, and continue with deep breathing and coughing exercises.
Mr Ramamurthy was very weak on admission to hospital, but has gained weight with
dietitian input. He will need ongoing monitoring of his diet.
If you have any queries, please contact me.
Yours sincerely,
Charge Nurse
