Selecting case notes
What to leave out matters as much as what to include.
15 minutes · A free lesson from Writing
Turning notes into professional sentences
Opening
- I am writing to refer…
- I would be grateful if you could review…
- Mr X, a 52-year-old taxi driver, presented with…
History and findings
- He reports a six-week history of…
- On examination,…
- His ECG showed…
- She has been using a walking frame since admission.
Request and close
- I would appreciate your assessment of…
- Please do not hesitate to contact me if you require further information.
Lesson quiz
Check what you have learned. Choose an answer to see whether it is right, and why.
Quick check: Which question decides whether a case note goes in?
- Is it the longest note?
- Does this reader need it to do what I am asking?
- Is it the first note on the page?
Show the answer
B: Does this reader need it to do what I am asking? — What you leave out matters as much as what you include.
Quick check: You are writing to a district nurse. Which note matters most?
- The patient once taught primary school
- The patient's favourite food
- Wound care, mobility and the home situation
Show the answer
C: Wound care, mobility and the home situation — Choose what this reader needs for the care you are asking for.
Quick check: Which is the right way to write “BP 152/94”?
- His blood pressure was 152/94 mmHg.
- BP 152/94.
- B.P. high, 152/94
Show the answer
A: His blood pressure was 152/94 mmHg. — Do not copy note form. Write full sentences.
Practise: a nursing referral
Marked as soon as you finish — free with an account.Practise now
Marked as soon as you finish — free with an account.Practise now
Practise: a medical referral
Marked as soon as you finish — free with an account.Practise now
Marked as soon as you finish — free with an account.Practise now