Lots of you have asked me both here and on my youtube channel for case notes for the nursing Occupational English Test. I feel very honoured that so many nurses follow my website and watch my videos!
I have been very lucky to meet Suzanne Carroll from Medical English Direct who not only is an experienced English teacher and OET tutor, but is also a qualified Nurse from the UK! She has written some excellent case notes specifically for OET nursing which are below. There is also a sample letter to use for your OET preparation.
If you would prefer the case notes and sample letter in pdf form you can download it here:
Disclaimer:These case notes are intended purely for educational use and do not constitute medical advice. They are written in a similar style to OET format, but are not official OET material.
OET Writing Case Notes Nursing:
Mr Ivan Thompson is a 35-year-old patient on the surgical ward of Greenville Hospital. You are the Charge Nurse.
PATIENT DETAILS
Name: Ivan Thompson
DOB: 1/8/1984
Marital Status: Married
Admission date: 8/6/2019
Discharge date: 10/6/2019
Social background:
IT worker
Travels a lot for work
Plays football
2 children
Lives in a 3 bedroom rented house
Drinks 2-4 units of alcohol, per week. Socially.
Medical Background:
2004 Colles fracture, ORIF
2001- Appendectomy
Smoker –smokes 5 cigarettes per day. More on weekends.
Reason for Admission:
Perianal abscess. Pt referred by GP. Painful swelling near anus. Pus collection (slightly yellow in colour, no offensive odour). Pt discomfort. Area swollen.
VS on admission: Temp: 37.6, HR 88 bpm, Sats 98%, RR 22, BP 149/80
Treatment:
9/6/19 Incision and drainage (I & D) under general anaesthetic.
Allergies: NKDA
Medications:– Post- op, paracetamol 1g (QDS, PRN) and ibuprofen 200mg-400mg (TDS, PRN) post procedure. (Patient advised to not use ibuprofen long term)
Metronidazole: 500mg every 8 hours for 7 days. Course to be completed at home (orally)
Nursing Management and Progress:
Daily dressings (to the right of the anus). Analgesia recommended to be taken before dressing changes first few days.
Currently 2cm in length and 1.5cm in width
Wound being cleaned with prontosan, packed with kaltostat and tegaderm for sealing.
Assessment: Pt showing no signs of infection on discharge. All observations normal.
Bowels opened post-surgery, aid of stool softener
Discharge Plan:
Daily wound dressings as exudate ++.
Continue with dressing choice as you see fit (see above for current dressing choice)
Monitor for signs of infection
Encourage Pt to finish course of ABX
Refer back to hospital if any concerns with healing
If pt has a lot of pain when opening bowels we have advised to use stool softener and eat a fibre based diet
Pt has a follow up review at Surgical Outpatients Department, Greenville Hospital in 6 weeks.
Writing Task:
Using the information in the case notes, write a letter to the GP Nurse, Greystone General Practice, 57 Sand Lane, Greystone asking for wound care and monitoring post-discharge.
Expand the relevant notes into complete sentences
Do not use note form
Use letter format
180-200 words
Sample response:
GP Nurse
Greystone General Practice
57 Sand Lane
Greystone
10th June 2019
Dear Nurse,
Re: Ivan Thompson, DOB 01/08/1984
Thank you for seeing Mr Thompson, who was admitted on the 8th June 2018, due to a perianal abscess. He will require wound care following an incision and drainage yesterday and will be discharged today.
Post operatively, Mr Thompson is observationally stable. The incision site, slightly to the right of the anus, is currently 2cm(width) x 1cm(length) and has been cleaned daily with prontosan, packed with kaltostat and sealed with a tegaderm. On discharge, nil signs of infection were noted.
The patient has been advised to take pain killers before dressing changes for the next few days and has been warned against long term use of ibuprofen. In addition, Metronidazole (500mg PO, q8hrs) was prescribed for one week as prophylactic cover. Please ensure Mr Thompson finishes his course.
I would be grateful if you could continue to dress the wound daily as it is producing a lot of exudate. Please monitor for any signs of infection and do not hesitate to refer Mr Thompson back to the hospital should you have any concerns.
Please note we have advised that he uses a stool softner as when needed for short term use to reduce any discomfort. *195 words
If you have any queries, please do not hesitate to contact me.
Yours faithfully,
Charge Nurse
I hope these were useful!
Written by Suzanne Carroll: Medical English Direct www.medicalenglishdirect.com, Facebook: Medical English Direct
Please get in touch with her at the above links if you are looking for 1:1 online OET lessons with a nurse, native speaker and English teacher. I can personally say she is also a very lovely person!
As usual, let me know in the comments if you have any questions!
Can’t I write about his social background here.
Can we write social background as well?
GP Nurse
Greystone General Practice
57 Sand lane
Greystone
11th January 2024
Dear Nurse
Re: Ivan Thompson DOB: 1/8/1984
I am writing to refer your patient Mr Ivan Thompson for continuous wound care and monitoring following post surgical procedure due to perianal abscess.
Mr Thompson was admitted on 8/6/2019 due to painful swelling and discomfort near the anus. Incision and drainage was done on Mr Thompson under general anesthesia.
Postoperatively, paracetamol 1g PRN and ibuprofen 200-400mg PRN was prescribed and has been advised on long term use of ibuprofen. In addition, metronidazole 500mg q8hrs was also prescribed for one week as prophylactic antibiotics. Please ensure that Mr Thompson completes his course of antibiotics.
Wound is being cleaned with prontosan, packed with kaltostat and tegaderm for sealing. Patient has been advised to take pain killer before changing the dressing for the first few days.
I would appreciate if the wound is continually dressed on a daily basis and monitored for signs of infection. Please refer Mr Thompson back to the hospital should you have any concern.
Do not hesitate to contact me if you have any queries.
Yours faithfully,
Charge Nurse
192words
I AM PREPARING TO WRITE MY OET IN TWO WEEKS, KINDLY ASSIST.
THANK YOU
GP Nurse
Greystone General Practice
57 Sand Lane
Greystone
16th December 2022
Dear Nurse,
RE: Mr. Ivan Thompson, DOB 01/08/1984
I would like to refer the case of Mr. Ivan Thompson for wound care and post-discharge monitoring.
Mr. Thompson was admitted on June 6, 2019 with a chief complaint of Perianal Abscess. He had a procedure the following day which was an Incision and Drainage under General Anesthesia.
Today, he is for discharge with stable vital signs and noted without the signs of infection. It is recommended to do daily dressing to the right anus, and take pain medications prior to his wound care for the first few days. The incision site is about 2cm in length and 1.5cm in width, and It is cleaned with prontosan packed with kaltostat sealed with tegaderm.
Mr. Thompson has a post-operative take home medications of pain relievers and antibiotic. He was advised not to use the Ibuprofen for long term, and properly instructed to complete his antibiotic therapy. In the event that the patient will have a difficulty of bowel movement, and experience pain, he was advised to eat foods rich in fiber and has a stool softener as an aid.
He is booked for follow-up appointment in 6 weeks at Surgical Outpatient Department in Greenville Hospital.
Should there be any concerns that requires immediate medical attentions, please refer back the patient to the hospital.
Please do not hesitate to call the undersigned for any further inquires.
Yours faithfully,
Charge Nurse
GP Nurse
Greystone General Practice
57 Sand Lane, Greystone
June 10, 2019
Dear Sir/Madam,
Re: Mr Ivan Thompson, aged 35.
I am writing to refer Mr Thompson who suffers from perianal abscess for further care following his discharge today.18
Mr Thompson was admitted due to painful and swollen area near the anus with pus collection. He underwent incision and drainage under general anaesthesia. Postoperatively, he was treated with pain medications and antibiotics. Painkillers are recommended to be given prior to dressing changes in the first few days postoperative. In addition, daily wound dressing was done with prontosan, packed with kaltostat and covered with tegaderm to lessen the exudates. Currently, the wound measures 2cm long and 1.5cm wide.75
On discharge, Mr Thompson was advised not to take ibuprofen for an extended time and to complete the course of antibiotics. He was also instructed to continue the use of a stool softener and to eat foods rich in fibre to avoid straining. Mr Thompson is now clinically stable with no signs of infection.52
It would be appreciated if you could monitor Mr Thompson’s surgical site for signs of infection and provide proper wound care. Please refer him back to the hospital in case concerns regarding wound healing arise. A follow up review at the Surgical Outpatients Department Hospital has been arranged for him in six weeks.52
If you need further information, please don’t hesitate to contact me.
Yours sincerely,
Charge Nurse
Can we write The General Practioner Nurse ?
Ok…. In this writing task how many pragraph
GP Nurse
Greystone General Practise
57 Sand Lane, Greystone
February 5, 2022
Dear Nurse
Re: Ivan Thomspson
DOB 1/8/1984
I am writing to refer to you Mr. Thompson, 35-year-old, who was admitted due to perianal abscess. He is stable and fit for discharge today but will require your continuing care and monitoring of his wound.
On admission, he presented with a painful swelling with pus collection near his anus. Incision and drainage was then performed under general anaesthesia. Currently, the wound is 2cm long and 1.5cm wide in size. Due to massive exudates, it is cleaned daily with prontosan, packed with kaltostan and tegaderm to seal. The wound still fresh and painful so analgesia is recommended prior to changing dressings. Please observe for any signs of infection and refer back to us if any problems with healing.
He was prescribed with medications post surgery, this includes paracetamol 1g ( 4 times a day, PRN), ibuprofen 200-400mg ( 3 times a day, PRN) and metronidazole 500mg every 8 hours for 7 days. The patient was advised that ibuprofen is not ideal for long term use and to make sure to complete the course of his antibiotic. He was encouraged too, to use stool softener and eat a high fibre diet if having difficulty opening bowel.
In 6 weeks, Mr Thompson has a follow up review at Surgical Outpatient Department Greenville.
Do not hesitate to contact me with any queries.
Yours faithfully
GP Nurse
Greystone General Practice
57 Sand Lane
Greystone
10 June 2019
RE: Ms. Ivan Thompson, DOB: 1 August 1984
Dear Nurse,
I would like to refer Ms. Ivan Thompson who underwent an incision and drainage due to perianal abscess. She would require wound care and monitoring upon her return home today.
Ms. Thompson presented to our hospital on 8 June with complaints of discomfort near her anus. She is slightly febrile and has elevated blood pressure of 149/80. She was subsequently scheduled for surgery the next day.
Ms. Thompson’s wound size is 2cm in length and 1.5cm in width. Her wound site is being managed by daily cleaning and dressing using prontosan, kaltostat and sealed with tegaderm. She was prescribed with metronidazole, 500mg, q8 for 1 week. At the moment, her recovery progress is good and shows no signs of infections.
Given the above information, I would appreciate if you could continue Ms. Thompson’s wound management. Kindly observe for signs of infection and refer back to hospital if problem with healing is observed. Also, as she experiencing pain during bowel opening, it is recommended to use stool softener and consume fibre rich food. Lastly, please encourage her to continue and finish her oral antibiotics.
She is scheduled to come back at Surgical Outpatient Department after 6 weeks.
If you have any concerns, please do not hesitate to contact me.
Yours faithfully,
Charge Nurse
Be mindful of your preposition. Using “she” for a male noun is a grave mistake in language exams.
will this be alright as sample OET writing answer?
(feel free to comment, let us all learn together)
04 September 2021
GP Nurse
Greystone General Practice
57 Sand Lane
Greystone
Dear GP Nurse,
Re: Mr. Ivan Thompson, DOB 01/08/1984
Mr. Thompson needs your professional assistance regarding wound care and monitoring following post-surgical procedure of his perianal abscess.
Mr. Thompson was admitted on 8/6/2019 at Greenville Hospital having chief complaint of pain and discomfort due to swelling and pus collection near his anus, hence he was referred to GP.
The following day, Mr. Thompson undergo Incision and drianage (I&D) surgical treatment on his perinal abscess under general anaesthetic. Medications were prescribed and started accordingly. For pain relief, he received Paracetamol 1g (QDS, PRN) and Ibuprofen 200mg-400mg (TDS,PRN). He also received initial doses of Metronidazole 500mg every 8 hours, this can be completed at home via oral route for 7 days.
Mr. Thompson’s wound is currently 2cm in length and 1.5cm in width. It is strongly advised to administer pain killers prior to dressing change for the first few days. His post-operative wounds were being cleansed daily with prontosan then packed with kaltostat and tegaderm for sealing.
Mr. Thompson is now fit for discharge, all observations were unremarkable and there were no signs of infection. He was able to pass stool with aid of stool softener.
Mr. Thompson requires daily wound dressings because of increased in exudates, you may continue using the same type of dressings mentioned above or you may opt to use any dressing of your choice. Kindly monitor for any signs of infection and encourage him to complete the course of the antibiotics as prescribed for 7 days. If pain still persists upon passing stools, stool softener has been advised as well as increasing consumption on fibre to be added on his diet.
Mr. Thompson has a follow up review at Surgical Outpatients Department, Greenville Hospital in 6weeks. On the other hand, if there is any concern with healing process, kindly refer him back to the hospital.
For any queries, please feel free to call me.
Sincerely,
Charge Nurse
04 September 2021
GP Nurse
Greystone General Practice
57 Sand Lane
Greystone
Dear GP Nurse,
Re: Mr. Ivan Thompson, DOB 01/08/1984
Mr. Thompson needs your professional assistance regarding wound care and monitoring following post-surgical procedure of his perianal abscess.
Mr. Thompson was admitted on 8/6/2019 at Greenville Hospital having chief complaint of pain and discomfort due to swelling and pus collection near his anus, hence he was referred to GP.
The following day, Mr. Thompson undergo Incision and drianage (I&D) surgical treatment on his perinal abscess under general anaesthetic. Medications were prescribed and started accordingly. For pain relief, he received Paracetamol 1g (QDS, PRN) and Ibuprofen 200mg-400mg (TDS,PRN). He also received initial doses of Metronidazole 500mg every 8 hours, this can be completed at home via oral route for 7 days.
Mr. Thompson’s wound is currently 2cm in length and 1.5cm in width. It is strongly advised to administer pain killers prior to dressing change for the first few days. His post-operative wounds were being cleansed daily with prontosan then packed with kaltostat and tegaderm for sealing.
Mr. Thompson is now fit for discharge, all observations were unremarkable and there were no signs of infection. He was able to pass stool with aid of stool softener.
Mr. Thompson requires daily wound dressings because of increased in exudates, you may continue using the same type of dressings mentioned above or you may opt to use any dressing of your choice. Kindly monitor for any signs of infection and encourage him to complete the course of the antibiotics as prescribed for 7 days. If pain still persists upon passing stools, stool softener has been advised as well as increasing consumption on fibre to be added on his diet.
Mr. Thompson has a follow up review at Surgical Outpatients Department, Greenville Hospital in 6weeks. On the other hand, if there is any concern with healing process, kindly refer him back to the hospital.
For any queries, please feel free to call me.
Sincerely,
Charge Nurse
HIE HANNAH THANKS SO MUCH VERY INFORMATIVE
Hi Hanna I am struggling for my oet and I have come through most of the famous sites but you are one of the best teachers. I am so impressed by the way you address topics.Thank you
Hello Hannah
I came across your website by chance. I am glad its really useful ☺ all your videos are excellent.
Thank you
Hello Hannah
I came across your website by chance. I am glad its really useful ☺ all your videos are excellent.
Thank you
It’s a sample letter and i have gained a lot of knowledge regarding lettering and currently preparing to write.
Hi Hannah,
God bless you for all the help you are providing.
I was so glad to see your new video on YouTube about speaking.
Thanks once again for all.
Thank you so much Joana!
It is very helpful to improve my reading ,as I am struggling to pass my oet reading part A
Thank you, glad it was useful!