Sample Nurse Case Notes and Letter

for OET review
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  Sample Nurse Case Notes: Nina Sharman Time allowed: 40 minutes  Read the case notes below and complete the writing task which follows: Today’s Date: 21/03/12   Patient Details  Name: Ms Nina Sharman DOB:09/02/1951 New resident of Dementia Specific Unit, Westside Aged Care Facility Single Under the Australian Guardianship and Administration Council protection Medical History  Ischemic heart disease (IHD) since 2005, takes Nitroglycerine patch, daily Stroke May 2011, after stroke - unsteady gait In 2011 - diagnosed with severe dementia - able to understand simple instructions only, confused and disorientated Diabetes mellitus (type 2) since 2000 –  on a diabetic diet Osteoarthritis of both knees 20 yrs. Voltaren Gel to both knees BD Weight gain 10kg over the last 5 months, current weight 106kg (BMI of 30) Chronic constipation,takes Laxatives PRN No allergies to medication or food No teeth –  has entire upper or lower dentures, sometimes refuses to wear dentures due to confusion and disorientation Increased appetite –  usually eats full portion of offered meals x 3 times daily and, also,goes into other residents’ rooms and eats their food as bananas, biscuits or lollies Social History  no friends lack of interests, but likes colouring and watching TV ↑  emotional dependence on nursing staff non-smoker, no use of alcohol or illegal drugs Recent Nursing Notes  15/02/12 Chest infection. Keflex 500mg QID x 7 days 26/02/12 Occasional cough & episodes of SOB with ↑  RR 27/02/12 Sporadic throat clearing after eating yoghurt 20/03/12 1700 hrs Episode of choking on a piece of food (? food not chewed properly). She suddenly turned blue, grabbed the throat with both hands and coughed. The piece of solid food was removed. 1710 hrs Nursing assessment after treatment    Pulse 110 BPM    BP 120/70 mmHg    RR –  22/min    T –  37.1 ° C    BSL –  6.0 mmol/L 1800 hrs    No complaints.    Pulse –  88 BPM     BP –  115/70 mmHg    RR –  16/min    T-37.0 ° C.    Skin: normal colour    Hospital visit not required WRITING TASK  You are a Registered Nurse at the Dementia Specific Unit. Using the information in the case notes, write a letter to Dietician, at Department of Nutrition and Dietetics, Spirit Hospital, Prayertown NSW 2175. In your letter explain relevant social and medical history and request the dietician to visit and assess Ms Sharman’s swallowing function and nutritional status urgently due to a high risk of aspiration.    Do not use note form in the letter    Expand on the relevant case notes into complete sentences    The body of the letter should be approximately 200 words long    Use correct letter format  21/03/2012   Dietician   Department of Nutrition and Dietetics   Spirit Hospital   Prayertown   NSW 2176   Dear Dietician,   Re: Ms. Nina Sharman   DOB: 09/02/1951   Thank you for seeing this patient, a 61-year-old single female resident of our Dementia Specific Unit, who had an episode of choking on a piece of food on 20/03/12. She requires an urgent swallowing and nutritional assessment due to a high risk of aspiration and chest infection.   Ms. Sharman’s condition has been deteriorating since May, 2011, when she suffered a stroke. Over the last year she has developed advanced dementia and is now confused and disorientated. Apart from this, she is edentulous for both upper and lower teeth and sometimes refuses to wear dentures due to her confusion. Her appetite has increased recently, and she has gained 10kg of weight over the last 5 months. Her current weight is 106kg (BMI of 30). Ms. Sharman also complains of chronic constipation. She has no allergies to medication or food. Her vital signs and blood sugar level were all within normal limits.   In regards to her medical history, Ms Sharman has been living with type 2 diabetes since 2000, which has been managed by a diabetic diet only. She was also diagnosed with ischaemic heart disease in 2005 and has had osteoarthritis for the past 20 years. If you require any more information, please do not hesitate to contact me.   Yours sincerely,   Registered Nurse   Dementia Specific Unit    Westside Aged Care Facility    Nurses      Discharge to a community nurse: focus on medical history and on going care required      Discharge to social worker: focus on social factors rather than medical details. Use lay language rather than technical jargon      Transfer to palliative care: focus on medical history and on going care required      Letter to General Public: provide advice on a medical topic such as first aid for burns      Psychiatric condition: focus on social factors & behavioural problems and issues      Letter to a doctor: focus on medical history and medication   Writing Dos & Don’ts   Below are a list of simple points to remember on the day of your exam.  Do   Don't   Summarise all the information from the case notes into sections such as: treatment given and obvious trends, medication, medical history. This will be both easier to write and read as well as avoiding repetition.   Follow a strict chronological order as your letter may become too long, difficult to read and will not focus on the main problem and related factors.   Try to write somewhere between 180 and 200 words for the body of the letter. This is the basic requirement of OET.   Write over 220 words as it may affect your overall result. You being tested on your ability to write a clear concise letter, not a long letter. Don’t write under 160 words as there may not be sufficient range language to get a B grade.   Omit information which is not directly relevant to your task. This is a big trap for many candidates in that they try to write down all the information from the task sheet. This does not reflect reality.   Try to put all the information from the case notes into the letter. Your letter will be too long and also poorly organised and difficult to read   Expand on all acronyms. For example OPG should be written Overuse acronyms. You are being tested on you ability to expand
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