Discharge Letter

Notes:

Name: Mrs Jane LaPaglia

Age: 71
Cultural & religion data: Italian & Catholic, speaks functional English
Admission Date: 4th March 2011 – Prince Albert Hospital
Discharge Date: 28th April 2011
Diagnosis: Renal failure 2⁰ to dehydration, mild dementia, pneumonia

Social/Medical family:
* Lives with 80 yr old husband/carer, Joe, in a 4 bdrm unit
*Joe not coping with pt’s or his own care needs
*House filthy, both have poor hygiene and nutrition
*One son, Andrew, a mechanic, visits Tuesday and Sunday
*Interests include classical music, ballet and AFL.

Medical History and Medications:

See Dr’s notes (to be forwarded)

Management and Progress during Hospitalisation:

*Initially comatose, ventilated in ICU 7/7
*Given dialysis 3/52 which ↓ urea & creatinine, stable now
*Hospital acquired pneumonia 2/24 chest physio for 2/52, still requiring O2 2 litres via nasal prongs but non
infective for 3/52.
*↑confusion post ICU but now back to usual mild level and is quite settled.
*Needs prompting to eat, drink, dress, walk, toilet & tend to personal hygiene but can independently do these
*Family conference 25/3/11. Consensus decision: pt will move to nursing home & Joe will live in adjoining hostel –
nil beds for either till 28/4/11.

Discharge Plan:
*Transfer to nursing home
*Husband will live in hostel next door, both accepting of this
*Continue O2 therapy as per O2 sats
*Encourage independence, pt capable of self-care with ++ prompting
*Ensure adequate hydration to prevent ↓renal function
*Repeat electrolyte, urea & creatinine blood test weekly

Writing task
You are the Charge Nurse on the medical ward where Ms LaPaglia has spent most of her hospital stay as a
patient. Using the information in the case notes, write a referral letter to the Charge Nurse at Boronia Nursing
Home, Coogee where Mrs Jane LaPaglia will be discharged to from your ward.

In your answer:

 Expand the relevant notes into complete sentences

 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.