In the following table, we will divide the case notes to small parts and discuss what you should do in each part.

Study this lesson carefully and know how a real case notes is organized.  The third column is very informative.

Test Information.
You needn’t read this section since it is always the same and known to you:
Test Information.Read the case notes below and complete the writing task which follows.Nil
Case Information
You will read this clearly and get an idea about your role and about the patient.


You are a Registered Nurse at Pullman Medical Centre. Ms. Paula Anderson is a patient in your care who is being transferred to Holy Heart Hospital today for a colostomy scheduled on 05/02/2018.

  1. Patient’s name
  2. Your name / designation
  3. Purpose
  4. Recipient
Patient Details.


Although social details are given, you need to mention them in the second last paragraph (Before the Request Paragraph)

  • Name: Ms. Paula Anderson
  • Today’s date: 02/02/2018
  • DOB: 19/05/1954
  • Marital status: Married
  • Social background: Lives with husband – very supportive
  • 1 daughter-lives interstate Two sisters- live nearby
  • Retired school teacher (English)
  • Hobbies: playing badminton, watching movies
  • Likes socializing, playing chess
  • Sedentary lifestyle – Overweight since 30’s
From this section, you can write sentences like:


  • Ms Paula Anderson is being transferred into your care for her scheduled colostomy…
  • A retired school teacher, Ms Anderson lives with her supportive husband…
  • She likes socializing and spends time playing chess…

You can pick the date of the letter from this section.

Medical History of the patient.
  • Appendectomy – 2003
  • # left leg – 2007
  • Pneumonia – 2015
  • Arthritis in hands – uses Voltaren
From this section, you can write sentences like:


  • Ms Anderson underwent appendectomy in 2003…
  • Please note that she had developed pneumonia in 2015…
Diet & Habits
  • Diet: Red meat, processed meat, fast food
  • Alcohol (Vodka, wine) – 4-5 days/wk.
  • Ex-smoker – quit 15 years ago
From this section, you can write sentences like:


  • Ms Anderson’s diet includes red meat, processed meat and fast food…
  • Although she was a smoker, she quitted the habit 15 years ago…
Nursing Notes


Sometimes nursing notes can be very long. If many visits are mentioned, do not include them all in your letter.



  • Visit to GP, 2- 3 bleeding from rectum
  • Rectal exam- definitely palpable mass
  • Fast track referral for suspected colorectal cancer


  • 8 cm mass on left lateral wall of rectum likely to be carcinoma – referred for colonoscopy


  • Colonoscopy- biopsies large bowel mucosa taken


  • CT & Local staging of primary tumour with MRI


  • Review of histology – colonoscopy report
  • Diagnosis – Colon cancer
  • R/v by colorectal and general surgery consultant
  • CT – no evidence of metastatic cancer
  • Recommended colostomy
  • Pt. advised of diagnosis and surgery


  • Identified needs/problems
  • Prepare for colostomy
  • Eating and drinking: Potential problems of dehydration due to above
  • Anxious about probs of stoma on home and social life. Involve family members in care


  • Minimise risk of post-op.,
  • Wound infection from bowel contents
  • Allow surgeons clear access to operation site, i.e. free from faeces
  • Complete pre-op. Care schedule
  • Encourage patient to voice concerns
From this section, you can write sentences like:


  • Ms Anderson visited her GP back last year following three episodes of rectal bleeding
  • A rectal examination confirmed the presence of palpable mass in the rectum…
  • She was put on a fast track referral for suspected colorectal cancer…

Note, there are several visits! In such cases, you needn’t mention all of them. Just pick the significant developments and frame a sentence or two to present them.


Discharge Plan
  • Rectal wash-out before bedtime for three days (daily)
  • Purgatives as desired
  • Low-residue light diet 02/02
  • Fluids only including soup and ice cream 02/03
  • Clear fluid 02/04
  • Charge Nurse to see the pt. to discuss practical problems at home
  • Nil by mouth from 00.00 hours 02/05
  • Standard pre-op procedure
  • Ensure variety of acceptable drinks
From this section, you can write sentences like:


  • Based on the information above, kindly provide preoperative care and monitoring for Ms Anderson…
  • Please note, she should not eat or drink from the midnight before the surgery…
Writing Task.
It is here you get a complete idea about the purpose of the letter.


Using the information given in the case notes, write a letter to Ms. Meredith Stevens, Charge Nurse, Holy Heart Hospital, 119 Red Sparrow Road, Docklands, Melbourne outlining relevant findings and patient care plan to prepare Ms. Anderson for the surgery.

You get the most important information from this area, so read this section of the case notes at the starting.
Test InformationIn 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.


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