Discharge Letter Writing Guide for OET Candidates

Recipient’s Name
Designation/Job title
Address

Greeting (Dear ……. )

Reference line (Re: the patient’s full name & age)

Tip 1: ‘20 January 2022’ is the preferred date format at the start.

Tip 2: dd/mm/yyyy is the preferred date format in in the reference line and paragraphs. (Avoid switching date formats in the reference line and paragraphs.)

Tip 3:  Interchanging the order of Date & Recipient’s Details is acceptable.

Tip 4:  Interchanging the order of Greeting & Reference Line is acceptable.

Tip 5:  If the DOB of the recipient is not given in the case notes, write age in the reference line. (You may use aged 63, aged 63 years, 63 years old or 63 years of age)

Tip 6: Watch the spelling. If you are using British/American spelling, be consistent in the letter. Avoid mixing the styles.

Ms Georgine Ponsford
Resident Community Nurse
Community Retirement Home
103 Light Street
Newtown

10 February 2019

Dear Ms Ponsford,

Re: Mr Lionel Ramamurthy, aged 63

Writing ‘introduction’ of a referral OET letter is similar to other types of letters such as a referral or a letter.

It covers the full name of the patient, introduces the medical complaint and generally discusses the reason(s) for writing the letter.

Tip 7:  Refer ‘Notes’, ’22 Jan 2019’ and ‘Writing Task’ given at the start and end of the case notes respectively to identify the purpose.

Tip 8:  Keep in mind that excluding the purpose would affect your score negatively.

Tip 9:  You may use the key word ‘discharge’ to indicate the purpose as you are discharging the patient to back his residential location.

Tip 10:  Keep the introduction succinct to make the purpose immediately apparent to the reader.

TIP 11: Avoid secondary information/details that may obscure the objective of introduction.

Tip 12:  Write full name with title at the first occurrence in the introduction as the patient is an adult. (Adult – aged above 16)

Tip 13:  Please note, ‘Writing Task’ says the patient is being discharged ‘tomorrow’. Date of discharge is also given as ‘11 Feb 2019.’

Tip 14: Avoid using ‘a/the/this/my patient’ to refer to the patient in the letter as it is considered less polite.

Introduce the patient: Refer PATIENT DETAILS and WRITING TASK.

PATIENT DETAILS:
Name: Lionel Ramamurthy (Mr)
Admission date: 04 Feb 2019
Discharge date: 11 Feb 2019
Diagnosis: Pneumonia

Medical Complaint: Refer Treatment Record

Diagnosis: Pneumonia

Reason for writing the letter: Refer Writing Task.

            … back to the retirement home upon his discharge tomorrow

The introduction of your OET letter is now

I am writing regarding Mr Lionel Ramamurthy, who was admitted on 04/02/2019 due to pneumonia. He is being discharged back into your care tomorrow.

Tip 15:  Identify relevant information/details: The presenting condition of the patient is relevant in this letter as the progress is related that. Select the most relevant/obvious information.

Medical background: 

Admitted with pneumonia – acute shortness of breath (SOB), inspiratory and expiratory wheezing, persistent cough (–>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).

Tip 16: Avoid Irrelevant information: Please remember, the reader knows the patient and his background well. Therefore, the following can be excluded.

• Marital Status
• Residence
• Next of kin
• Past medical history
• Social background
• Medical history

Tip 17: Avoid short forms; it is less formal.

Tip 18:  Avoid using pronouns to refer to the patient at the first occurrence in a paragraph. Use last name (surname) with appropriate title when referring to the (adult – aged above 16) patient initially in a body paragraph.

Tip 19: Verb tense: Past tense is used here as the patient’s condition at the time of admission is discussed.

Let’s compile relevant information and compose the body paragraph 1 as follows.

On admission, Mr Ramamurthy had fever, severe shortness of breath, wheezing and chest and abdominal pain due to persistent cough. He was mobilising with a pick-up frame and required assistance with ADLs. He appeared weak and could walk only short distances that led to worsening of SOB.

Tip 20: Verb tense: Past tense is used here as the patient already received the care mentioned.

Let’s compile relevant information and compose the body paragraph 2 as follows.

During hospitalization, Mr Ramamurthy was encouraged to have proper nutrition, including oral fluids, and to ambulate as per physiotherapist’s review. Chest physiotherapy, including deep breathing and coughing exercises, were initiated. He was maintained in a sitting position more than lying to ensure postural drainage.

Tip 21: Verb tense: Present tense is used here as it is the patient’s condition, in which he is returning to the facility.

Tip 22: Use ‘currently’ as no specific date is given in the case notes.

This paragraph can be written as below.

Currently, Mr Ramamurthy has made good progress with normal inflammatory markers and has gained weight by 1.5kg after a dietitian review. However, he is slow but can perform ADLs independently. He still has slight chest and abdominal pain.

Refer ‘Discharge plan’.

Tip 23:  Give an introductory phrase to link the conclusion to the patient’s complaints and past medical history.

Tip 24: Make sure the tone used is polite and formal.

Tip 25: Avoid capitalizing generic drug name(s). (If you are using brand names, capitalize accordingly.)
0
Tip 26: Avoid short forms.

Tip 28:  A typical polite closing sentence can be written as the addressee can get back to the writer if he needs more information about the patient.

Tip 29: Avoid being overpolite.

Tip 30: Avoid including informal words and phrases.

For example, feel free to, ask me, call me.

A closing sentence can be written as given below.

If you have any queries, please contact me.

Yours sincerely (If the name of the recipient is given.)

Yours faithfully (If the name of the recipient is NOT given.)

Tip 32:  Write the name of the profession/designation indicated in the case notes. You may give the name of the hospital or organization if given (optional).

Tip 33: Leave a single blank space between all sections.

In this case, the name of the reader is given. Therefore,

Yours sincerely,
Nurse

10 February 2019

Dear Ms Ponsford,

Re: Mr Lionel Ramamurthy, aged 63

I am writing regarding Mr Lionel Ramamurthy, who was admitted on 04/02/2019 due to pneumonia. He is being discharged back into your care tomorrow.

On admission, Mr Ramamurthy had fever, severe shortness of breath, wheezing and chest and abdominal pain due to persistent cough. He was mobilising with a pick-up frame and required assistance with ADLs. He appeared weak and could walk only short distances that led to worsening of SOB.

During hospitalization, Mr Ramamurthy was encouraged to have proper nutrition, including oral fluids, and to ambulate as per physiotherapist’s review. Chest physiotherapy, including deep breathing and coughing exercises, were initiated. He was maintained in a sitting position more than lying to ensure postural drainage.

Currently, Mr Ramamurthy has made good progress with normal inflammatory markers and has gained weight by 1.5kg after a dietitian review. However, he is slow but can perform ADLs independently. He still has slight chest and abdominal pain.

In your care, it would be appreciated if you could provide Mr Ramamurthy with good nutrition, including oral fluids, eggs, fruits and vegetables, and monitor his diet. Please keep him warm and administer paracetamol for chest and abdominal pain.

If you have any queries, please contact me.

Yours sincerely,
Nurse