Read the case notes below and complete the writing task which follows.

Hospital: Royal Perth Hospital

Patient Details:            

Alfred Billy. 52 Years old

• Marital status: married
• Wife to be contacted if there is any sort of emergency: Maria Jennifer, Arillon City Arcade 207 Murray Street Perth

Admission Date: 21/03/2010

Discharge Date: 5/05/2010

Diagnosis: Skin cancer – BCC (Basal Cell Carncinoma) (neck) Nodular basal-cell carcinoma 

Past Medical: No prior hospitalization, no history

History  : _____

Social  : Truck Driver

History/Supports:

• Lives with his wife
• Habit of consuming liquor for th past 30 years
• Cigarette Smoker  
• Skin dark
• Religion: Protestant

Medical Progress          :

• Skin biopsy is taken for pathological study
• CCB – removal of
• Pain reliever panadein forte 500mg

Nursing:                        No complications noted

Management:              

Perfectly well at the time of discharge. No complain of any pain   

Discharge Plan:            

Daily obs. Medicine to be taken for one more week

Writing Task : You are the charge nurse on the hospital ward where Mr.  Alfred Billy has recently had his operation. Using the information provided in the case notes, write a referral letter to the  Community Nurse Head at  Care Well Hospital,  Birmingham, who will be attending to  Mr. Alfred Billy, following his discharge. In your answer: Expand the relevant case notes into complete sentences. Do not use note form.The body of the letter should be approximately 200 words. Use correct letter format.

Sample answer by Lifestyle Training Centre.

Community Nurse Head
Care Well Hospital
Birmingham

5/05/2010

Dear Nurse,
Re: Mr Alfred Billy, aged 52 years.

I am writing to refer Mr Billy, who requires continuity of care and management, following his discharge today. He is recovering from an operation that he underwent in our hospital for the removal of Basel Cell Carcinoma of neck.

At present, Mr Billy is perfectly well, and he does not have any complications or complains of pain. During hospitalization, his skin biopsy was taken for pathological study. In order to alleviate pain, he was administered with Panadien forte, 500mg, which needs to be continued for another week.

Mr Billy has no record of prior hospitalization; however, he has been consuming alcohol for the past 30 years; he also smokes cigarettes. In case of any emergency, please contact his wife, Maria Jennifer, who lives with him.

Based on the above information, it would be greatly appreciated if you could visit and monitor Mr Billy daily at his residence, providing care and support. His address is attached to this letter. Should you have further queries, please do not hesitate to contact me.

Yours faithfully,
Charge nurse.

(Words count: 183)

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