How to Expand Case Notes in OET Writing for Nurses

Tasnim

• December 12, 2024

As a healthcare professional preparing for the Occupational English Test (OET), mastering the art of expanding case notes is crucial. The writing sub-test re-quires you to transform a set of clinical notes into a coherent and professional letter, typically addressed to another healthcare professional. This task assesses your ability to communicate effectively in written English within a healthcare context. Here’s a comprehensive guide to help you excel in expanding case notes for your OET writing task.

1. Understand the Purpose of the Letter

Before diving into the expansion of case notes, it’s essential to understand the purpose of the letter. Is it a referral, a discharge, or a transfer letter? Identifying the purpose will guide the tone, content, and structure of your letter.

2. Identify the Key Information

Go through the case notes thoroughly and identify the key pieces of information relevant to the letter’s purpose. Highlight or underline critical data such as patient history, current condition, medication, and any specific instructions or follow-up needs.

3. Organise the Information Logically

Organise the extracted information into a logical flow. Typically, a referral or
transfer letter follows this structure:
• Purpose
• Patient’s medical background
• Current condition
• Treatment provided
• Recommendations and follow-up

4. Expand Abbreviations and Medical Jargon

When expanding case notes, it’s important to convert abbreviations and medi-
cal jargon into full forms and layman’s terms where appropriate. For example:
• “HTN” should be expanded to “hypertension.”
• “Rv” should be expanded to “review”.

5. Use Appropriate Linkers and Transitional Phrases
Ensure that your letter flows smoothly by using linkers and transitional
phrases. These help in connecting different pieces of information cohesively.
Examples include:
• “Additionally,”
• “In addition to,”
• “However”

6. Maintain Professional Tone and Formality

The tone of the letter should be formal and professional. Avoid using colloquial
language or overly casual expressions. Ensure that your writing reflects the
professionalism expected in a healthcare setting.

7. Be Concise but Comprehensive

While it’s important to be thorough, avoid unnecessary details that don’t add
value to the recipient. Be concise yet comprehensive in providing all the rele-
vant information required for the recipient to understand the patient’s condi-
tion and the next steps.

8. Proofread and Edit

Finally, proofreading and editing your letter are critical steps. Check for gram-
matical errors, spelling mistakes, and ensure that medical terms are used accu-
rately. Reading your letter out loud can also help catch any awkward phrasing
or unclear segments.

Examples:

Case notes:

1. Weight loss advised, review of diet – reduce ulcer reoccurrence
2. Pt. to take paracetamol p.r.n. (no more than 8/day, discontinue water 1 wk).
3. Pt. informed of importance of compression stockings, and bed rest, with leg
elevation.
4. Community nurse to change dressings (daily) – reduce irritation
5. Monitor for infection/healing rate

Sample answers:

1. She has been advised to modify her diet to lose some weight which will also
help reduce an ulcer reoccurrence.
2. She can take paracetamol when required for no more than a week.
3. Mrs Cruise has been given guidelines post-discharge, which include wearing
compression stockings, bed rest and leg elevation.
4. Her dressings need to be changed daily to reduce irritation.
5. To ensure her wound heals adequately, monitoring for infection is required.