How to choose the relevant data – Introduction
What is relevance checking?
in each writing case note, you will find a lot of data. You should include only those information that will help the recipient to decide further treatment plans for the patient.
To be more precise, follow these instructions:
What to include?
- Anything relevant / important.
- Anything that the recipient should know.
- Anything that can help the recipient make further treatment plans for the patient.
What not to include?
- Anything that is not relevant.
- Anything that will not help the recipient.
- Anything that the recipient can guess.
- Anything that the recipient needn’t be told.
NB: To decide what is relevant / irrelevant, you need to be knowledgeable about the recipient’s services:
|Emergency Doctor||Emergency Care, recent medication, etc.||Social areas, past medical areas, etc.|
|Social Worker||Social and Psychological services, medication, etc.||Medical terms, detailed medical areas, etc.|
|Home Care Agency||General care, medication, psychological care, etc.||Detailed medical areas, etc.|
|Patient’s Carer||Medication, Dos and Don’ts||Medical terms|
How to check the relevant data in OET writing case notes?
Checking the relevance of any particular notes item depends on 9 questions. You have to write down these questions and their answers in their order before starting the exam. Rather than reading the case notes from beginning to the end, focus on finding answers to these 9 questions:
- (Patient, Recipient, Request, Admission, Admitting Condition, Current Condition, Treatment Status, Discharge Status and Writer of the letter).
Checking Relevance against 8 information
For this, we are using Sydney Loten case notes but part by part. We will look at each section of the case notes and check their relevance against the 8 questions below. Read carefully:
|1||Patient||Ms Sydney Loten|
|2||Recipient||Ms jane Hall, Transition Care|
|3||Request||Transfer the patient to home|
Help with transfer
|4||Admission||April 11, (this year)|
|5||Admitting Condition||Multiple polyps|
|6||Current Condition (Prognosis)||Post polypectomy|
|8||Discharge Status||Being discharged|
|9||Writer||Nurse Practitioner, current facility|
In Step 2, you check if you know sufficiently about this case, the purpose of this letter, etc.
- About the present condition
- About any future complications
As a medical professional, you should have some extra information about the given condition.
- The patient shouldn’t drive for 24 hours following a polypectomy.
- Recovery is generally quick.
- Minor side effects such as gassiness, bloating, and cramps usually resolve within 24 hours.
- With a more involved procedure, a full recovery can take up to two weeks.
Avoid certain drinks and foods that can irritate the patient’s digestive system for two to three days after the procedure. These can include:
- Spicy foods
- Perforation of the bowel or rectal bleeding.
Contact the doctor immediately:
- Fever or chills, as these could indicate an infection
- Heavy bleeding
- Severe pain or bloating in your abdomen
- Irregular heartbeat.