Writing - Case Notes
Suggestions for Improvement
GrandMasterClass QualityCheck Sheet
1. Writing - Case Notes
2. Original Manuscript
3. Electronic Version
Ms Angel Philip
Community Health Nurse
20 July 2019
Re: Mrs Joanna Johan, aged 40
Dear Ms Philip,
Mrs Joanna Johan, who is an antenatal mother with pregnancy-induced hypertension and gestational diabetes mellitus. She requires regular home visits for monitoring and appropriate management following the discharged today.
On 15th July 2019, she was admitted with complaints of generalized oedema and palpitation. On observation the vital signs and blood investigations were remarkable. Therefore, haemoglobin level was changed from 6mg/dl to 11mg/dl after transfusing one pint of PRBS, as well as iron and calcium supplements needs to be continued. Thyroxin dosage has been increased to 100mcg for effective management of hypothyroidism. Despite anti-diabetic agents were administered, it is noted that the sugar levels were remained unstable; therefore, an endocrinologist has been suggested to commenced on insulin therapy. Labetalol 100mg has been commenced to manage the blood pressure.
During hospitalization, weight loss was noticed, information regarding further weight is necessary. Additionally, a dietician has been initiated for dietary management to improve the health conditions. Refraining from cabbage, spinach, soya foods, nuts, cookies and chocolates would be profoundly beneficial. Low salt and fat diet are advised.
Based on the aforementioned circumstances, education regarding self-administration with insulin, dietary pattern and medications compliance are essential. Regular monitoring for antenatal check-ups, vitals, FHS, blood and urine sugar levels, are suggested. Please note that TSH check-up has been scheduled after a week and on 28th July 2019 will be the next appointment.
In case any additional information is required, please do not hesitate to contact me.
Care Well Hospital
4. Necessary Corrections
PERSONALISED WRITING FEEDBACK: ROUND - ONE
1. Pregnancy-induced hypertension
2. ... who was diagnosed with pregnancy-induced hypertension and gestational diabetes mellitus, ...
3. ... requires regular home visits for routine monitoring and appropriate management ...
4. ... following the discharge today.
5. ... home visits ...
6. ... gestational diabetes mellitus ... [no need G capital letter]
7. mellitus - either the spelling is incorrect or the clarity is missing.
8. ... she ... [unnecessary capital S]
9. ... with the complaints of ...
10. Do not leave any space before 'commas' and 'periods'; leave one-letter space after them.
11. Therefore, one pint of packed red blood cells were transfused.
12. Consequently, the haemoglobin level increased from 6 to 11 mg/dl.
13. Continuation of iron and calcium supplements is recommended.
14. For effectively managing hypothyroidism, thyroxin dosage was increased to 100 mcg.
15. Despite administering anti-diabetic agents, ...
16. sugar levels remained unstable.
17. Therefore, on the recommendations of the endocrinologist, insulin therapy was commenced.
18. Labetalol 100 mg once daily has been prescribed for managing the blood pressure.
19. The concerned authorities should be notified regarding further weight loss.
20. Low-salt, low-fat and iron-rich diet is advised.
21. ... education ... [Capital E - unnecessary]
23. ... self-administration of insulin
24. dietary patterns
25. and medication compliance
26. .... education regarding ......... would be profoundly beneficial.
27. An appointment for review for checking thyroid stimulant hormone on 28 July 2019 has been scheduled.
28. Limit the word count to 200.
29. Rewrite the letter and submit within 6 hours.
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