NURSE:

Relevant Semi relevant Irrelevant

CURRENT MED/SURG Social Hx TOO OLD MED/SURG Hx or
Presenting issue or status Residence/Address-If laboratories
Medications commenced nurse don’t know pt.
Past MED/SURG Hx Family Hx If case notes are within
new/latest/abnormal/associated (living with who?) normal
-if reader knows pt. Single parent/divorced
(no need past med Hx) widow/er
MANAGEMENT PLAN
Abnormal observations in:
Diet Weight
Habits Mobility
Impairments /
Requirements/Support needs
Date of visit/s or upcoming
appointments
Psychological issues

DOCTOR
Relevant Semi relevant Irrelevant
CURRENT MED/SURG Social Hx TOO OLD MED/SURG Hx or
Presenting issue or status (living with who?) laboratories
Medications commenced
Past MED/SURG Hx Family Hx If case notes are within
new/latest/abnormal/associated normal
MANAGEMENT PLAN if reader knows pt. Single parent/divorced
(no need past med Hx) widow/er
Abnormal observations in:
Diet Weight
Habits Mobility
Impairments / Requirements
Date of visit/s
Psychological issues
PHYSIOTHERAPIST
Relevant Semi relevant Irrelevant
CURRENT MED/SURG Past MED/SURG Hx IF READER KNOWS PT (no
Presenting issue or status Associated ONLY need past Physical Hx)
Physical status: Abnormal observations If case notes are within
Wound/impairments in: normal
Diet Weight
Habits Mobility
CURRENT mobility Family Hx (living with Medications
who?)
Single parent/divorced
widow/er
MANAGEMENT PLAN
Assistive devices /
occupational therapy

SOCIAL WORKER
Relevant Semi relevant Irrelevant
CURRENT MED/SURG Abnormal observations Unassociated medical
Presenting issue or status in: condition
Diet Weight
Mobility
Social Hx (Habits) medication
Family Hx (living with
who?) single
parent/divorced
widow/er
MANAGEMENT PLAN residence
Impairments /
Requirements/Support
needs
Psychological issues
STEPS
FIRST 5 MINUTES

1.Read the task

2.Who are you writing to? READER (Home care nurse/Home visit nurse/ physio / social service/ specialist doctor)

Does the reader know the patient? If yes-Most likely he knows the past Hx

4.Reason for writing

Why are you writing? (referral/discharge/urgent admission)

5. Think what the reader needs to know (WHAT is relevant to the reader???)

What are the relevant case notes that the reader needs to know?

What case notes that the reader is involved in?

6. What is your role

7.What is the discharge plan

What case notes that the reader is involved in?

SELECTING CASE NOTES

HISTORIES (WHAT IS ASSOCIATED TO THE MAIN MEDICAL ISSUE????)
(WHAT is relevant to the reader???)
PAST MEDICAL HISTORY

Is it relevant to the current issue or condition?

if relevant prioritize which case notes comes FIRST
if SEMI RELEVANT (can be included but not in detail)

SOCIAL HISTORY

Is LIFESTYLE or FAMILY BACKGROUND connected to the current condition?

if SEMI RELEVANT (can be included but not in detail)

CURRENT HISTORY (dated case notes/just happened prior to admission/ presentation in clinic)

Are laboratories/ blood results still viable or already out dated?

Is it associated with the presenting/current issue?

if SEMI RELEVANT (can be included but not in detail)

HARVEY’S LETTER ORGANIZATION (WHAT is relevant to the reader???)

1ST PARAGRAPH – Reason for writing (MAIN MEDICAL ISSUE)

2nd PARAGRAPH – MAIN MEDICAL ISSUE in detail

3rd PARAGRAPH – Secondary or associated issues

4th PARAGRAPH – Associated Medical/Social History or secondary issue

5th PARAGRAPH – Management or Discharge plan

IF FROM CLINIC/HEALTH CENTER/HOME VISIT NURSE (with dates)

referring to hospital doctor/ homecare admission
(WHAT is relevant to the reader???)
1ST PARAGRAPH – (MAIN MEDICAL ISSUE) Information on RECENT VISIT

HOSPITAL ADMISSION/DOCTOR IN THE HOSPITAL

- I am writing to request hospital admission of Mr __ who has been assessed with _______

HOMECARE ADMISSION

- I am writing to request admission of Mr __ who has been assessed with _______

REFERRAL TO A DOCTOR

- I am writing to refer Mr___ who is presented

2nd PARAGRAPH – 1st visit issues + 2nd visit issues

- Initially, Mr ____ presented to our clinic on __/__/__

3rd PARAGRAPH – 2nd visit issues +/ 3rd visit issues

- On _/__/__, Mr___ attended/presented again with

- Mr____ attended/presented again ____week/s or month/s later with

4th PARAGRAPH – Recent visit

- On review today, there was no improvement

5th PARAGRAPH – Management or Discharge plan

- Given this history, I believe Mr______ has ____Dx__ and needs urgent admission

NOTES: - 1st 2nd or 3rd visit may be combined if paragraph is too short.
FROM HOSPITAL TO HOME CARE/COMMUNITY NURSE (home visit)

SAMPLE LETTER

1ST PARAGRAPH – Reason for writing (MAIN MEDICAL ISSUE)

I am writing to refer

I am writing to request urgent assessment for Mr______

2nd PARAGRAPH – MAIN MEDICAL ISSUE in detail

-During the course of her admission,

-Post-operatively,

3rd PARAGRAPH – Secondary or associated issues

-Medically, Mr_____

4th PARAGRAPH – Associated Medical/Social History or secondary issue

-Socially, Mr_____ lives with

- Mr_____ lives with

- Mr _____ is a ____ worker and lives alone

5th PARAGRAPH – Management or Discharge plan

-It would be appreciated

-Mr ____ will require a visit from the social worker

-(Doctor) It would be greatly beneficial if you could assess and manage Mr___ as you think is appropriate.