Understanding the Essentials of an OET Writing Discharge Letter Sample
Writing a discharge letter might seem straightforward, but it's a vital communication tool that bridges the gap between hospital care and a patient's life after leaving. A well-written discharge letter informs the receiving healthcare professional about the patient's condition, treatment received, and recommendations for ongoing care. The importance of a clear and comprehensive discharge letter cannot be overstated, as it directly impacts patient safety and treatment outcomes. Here are some key components often found in an OET Writing Discharge Letter Sample:- Patient Demographics: Name, age, gender, patient ID.
- Admission and Discharge Dates: When the patient came in and when they left.
- Diagnosis: The main reason for the hospital stay.
- Brief Hospital Course: What happened during the stay, including key investigations and treatments.
- Medications: A list of all medications prescribed at discharge, with dosage and frequency.
- Follow-up Plan: Instructions for the patient and the receiving doctor, including appointments, further tests, or lifestyle advice.
| Element | Purpose |
|---|---|
| Diagnosis | Informs about the patient's condition. |
| Treatment Summary | Details interventions and their effectiveness. |
| Discharge Medications | Ensures proper ongoing treatment. |
| Follow-up Instructions | Guides future care and patient actions. |
Discharge Letter Sample: Routine Post-Operative Recovery
Dear Dr. Anya Sharma,
Subject: Discharge Summary - Mr. David Chen (Patient ID: 12345)
This letter is to inform you about the discharge of Mr. David Chen, a 65-year-old gentleman, from our facility on October 26, 2023. Mr. Chen was admitted on October 20, 2023, for an appendectomy due to acute appendicitis.
During his stay, Mr. Chen recovered well from his surgery. His vital signs remained stable throughout. He was managed conservatively post-operatively with IV antibiotics (Ceftriaxone and Metronidazole), which were completed as per protocol. Pain management was achieved with paracetamol and occasional use of morphine. He tolerated a diet of soft foods and was mobilized with physiotherapy assistance.
At discharge, Mr. Chen is asymptomatic and ambulating independently. His wound is clean, dry, and intact.
Current Medications:
* Paracetamol 500mg, 2 tablets orally every 6 hours as needed for pain.
* Amoxicillin-clavulanate 875mg/125mg, 1 tablet orally twice daily for 7 days.
Recommendations:
We recommend a follow-up appointment with you in 2 weeks to review his progress and surgical wound. Please advise him to report any signs of infection such as increased redness, swelling, or discharge from the wound, or a return of significant abdominal pain. He can gradually return to his normal diet and activities as tolerated.
Thank you for your continued care of Mr. Chen.
Sincerely,
[Your Name/Hospital Department]
Discharge Letter Sample: Management of Pneumonia
Dear Dr. Ben Carter,
Subject: Discharge Summary - Ms. Sarah Lee (Patient ID: 67890)
This summary pertains to Ms. Sarah Lee, a 42-year-old female, who was discharged on October 26, 2023, following a 5-day admission for community-acquired pneumonia. She was admitted on October 21, 2023.
Ms. Lee presented with cough, fever, and shortness of breath. Chest X-ray confirmed right lower lobe pneumonia. She was treated with intravenous Levofloxacin, which was later switched to oral Levofloxacin as her condition improved. Her fever resolved within 48 hours, and her respiratory symptoms significantly diminished. She was able to mobilize independently and maintain adequate oral intake.
Upon discharge, Ms. Lee is afebrile, her cough is significantly reduced, and her oxygen saturation is stable on room air.
Current Medications:
* Levofloxacin 500mg, 1 tablet orally once daily for 5 more days.
* Dextromethorphan syrup, 15ml orally every 8 hours as needed for cough.
Recommendations:
We advise a follow-up with your clinic in 1 week to assess her recovery. She should be encouraged to continue with rest, adequate hydration, and avoid strenuous activity for the next week. A repeat chest X-ray is not indicated at this time unless her symptoms worsen. Please advise her to seek immediate medical attention if she experiences increased shortness of breath, fever, or chest pain.
Thank you for accepting Ms. Lee back into your care.
Sincerely,
[Your Name/Hospital Department]
Discharge Letter Sample: Chronic Condition Exacerbation (e.g., COPD)
Dear Dr. Emily Davis,
Subject: Discharge Summary - Mr. John Rodriguez (Patient ID: 11223)
This letter concerns Mr. John Rodriguez, a 72-year-old male with a history of Chronic Obstructive Pulmonary Disease (COPD), who was discharged on October 26, 2023. He was admitted on October 22, 2023, due to an exacerbation of his COPD.
Mr. Rodriguez presented with increased dyspnea, productive cough, and wheezing, requiring supplemental oxygen. He was treated with nebulized bronchodilators (Salbutamol and Ipratropium), oral corticosteroids (Prednisolone), and a course of Azithromycin. His oxygen requirement decreased, and his respiratory distress resolved. He was able to tolerate his usual home inhaler regimen prior to discharge.
Current Medications:
* Salbutamol inhaler, 2 puffs every 4-6 hours as needed.
* Tiotropium inhaler, 1 inhalation once daily.
* Prednisolone 20mg, 1 tablet orally once daily for 3 more days, then stop.
* Azithromycin 250mg, 1 tablet orally once daily for 2 more days.
Recommendations:
We recommend a follow-up appointment with your pulmonary clinic within 7-10 days to review his COPD management. Please ensure he has his usual inhaler technique reviewed. Advise him to continue with his prescribed medications and to contact your office if he experiences any recurrence of significant shortness of breath, increased sputum production, or fever. Regular review of his smoking cessation efforts would also be beneficial.
Thank you for your ongoing care for Mr. Rodriguez.
Sincerely,
[Your Name/Hospital Department]
Discharge Letter Sample: Patient Transfer to Another Facility
Dear Dr. Fatima Khan,
Subject: Transfer Summary - Ms. Maria Garcia (Patient ID: 44556)
This letter provides a summary for the transfer of Ms. Maria Garcia, a 55-year-old female, from our facility to [Name of Receiving Facility] on October 26, 2023. Ms. Garcia was admitted on October 24, 2023, for observation following a fall resulting in a mild concussion.
Ms. Garcia was assessed and monitored closely. She experienced no neurological deterioration and her symptoms resolved. She was deemed stable for transfer to [Name of Receiving Facility] for further rehabilitation and monitoring related to her fall and concussion.
Key Information for Transfer:
* Diagnosis: Mild Concussion, No Fracture.
* Current Condition: Alert, oriented, no acute distress.
* Vital Signs: Stable.
* Medications: Paracetamol 500mg orally every 6 hours as needed for headache.
Recommendations for Receiving Facility:
Please continue to monitor Ms. Garcia's neurological status. Advise her to avoid strenuous activities and seek medical attention if she experiences severe headaches, dizziness, nausea, vomiting, or changes in consciousness. We have provided her with a copy of her initial assessment.
Thank you for accepting Ms. Garcia into your care.
Sincerely,
[Your Name/Hospital Department]
Discharge Letter Sample: Pediatric Patient Discharge
Dear Dr. George White,
Subject: Discharge Summary - Master Leo Brown (Patient ID: 77889)
This summary is for the discharge of Master Leo Brown, a 3-year-old male, from our pediatric ward on October 26, 2023. He was admitted on October 25, 2023, with gastroenteritis.
Master Leo presented with vomiting and diarrhea. He was managed with intravenous fluids for rehydration and a clear liquid diet. His symptoms improved significantly, and he has been tolerating oral fluids and a bland diet without recurrence of vomiting or diarrhea. His vital signs are stable, and he is playful and alert.
Current Medications:
* Oral Rehydration Solution (ORS), offer frequently as per age-appropriate guidelines.
* [Name of Probiotic/Medication, if prescribed], 1 sachet daily.
Recommendations:
We recommend a follow-up with your clinic in 2-3 days if symptoms do not improve or worsen. Please advise the parents to continue with a gradual reintroduction of his regular diet, avoiding fatty or sugary foods for a few days. Ensure he stays well-hydrated. They should seek medical attention if Leo becomes lethargic, shows signs of dehydration (decreased urination, dry mouth, sunken eyes), or if his vomiting/diarrhea returns.
Thank you for your ongoing care of Master Leo.
Sincerely,
[Your Name/Hospital Department]
Discharge Letter Sample: Mental Health Patient Discharge
Dear Dr. Helen Kim,
Subject: Discharge Summary - Ms. Olivia Green (Patient ID: 00112)
This summary pertains to Ms. Olivia Green, a 28-year-old female, who was discharged on October 26, 2023, following a voluntary admission for management of acute anxiety and panic attacks. She was admitted on October 23, 2023.
During her stay, Ms. Green participated in individual and group therapy sessions focusing on cognitive behavioral techniques and relaxation strategies. Her anxiety levels significantly decreased, and she demonstrated improved coping mechanisms. She was stabilized on her home medication regimen and showed no further signs of acute distress or suicidal ideation.
Current Medications:
* Sertraline 50mg, 1 tablet orally once daily.
* Lorazepam 0.5mg, 1 tablet orally at bedtime as needed for sleep (no more than 3 times per week).
Recommendations:
We recommend a follow-up appointment with your psychiatric practice within 7 days to review her progress and medication adherence. Please encourage her to continue attending her scheduled therapy sessions. Advise her to contact your office or the emergency services if she experiences a significant increase in anxiety, panic symptoms, or any suicidal thoughts. Support groups may also be beneficial.
Thank you for your continued support of Ms. Green's mental health.
Sincerely,
[Your Name/Hospital Department]
Discharge Letter Sample: Diabetic Patient Discharge
Dear Dr. Ian Chen,
Subject: Discharge Summary - Mr. Robert Miller (Patient ID: 33445)
This letter is to inform you of the discharge of Mr. Robert Miller, a 68-year-old male with Type 2 Diabetes Mellitus, on October 26, 2023. He was admitted on October 24, 2023, for management of hyperglycemia.
Mr. Miller presented with elevated blood glucose levels and symptoms of poor glycemic control. He was educated on his diabetes management, including diet, exercise, and medication adherence. His blood glucose levels have normalized with adjustments to his oral medication regimen and his current insulin therapy. He has been advised on self-monitoring of blood glucose and has demonstrated competency in its use.
Current Medications:
* Metformin 1000mg, 1 tablet orally twice daily.
* Insulin Glargine, 20 units subcutaneously once daily at bedtime.
* [Name of other diabetic medication if applicable], [dosage and frequency].
Recommendations:
We recommend a follow-up appointment with your endocrinology clinic within 2 weeks to review his glycemic control and medication effectiveness. Please reinforce the importance of a balanced diet, regular physical activity, and consistent blood glucose monitoring. Advise him to seek immediate medical attention if he experiences symptoms of hypoglycemia (shakiness, sweating, confusion) or hyperglycemia (increased thirst, frequent urination).
Thank you for your ongoing care of Mr. Miller.
Sincerely,
[Your Name/Hospital Department]