TASK 26 Rend the case notes and complete the writing task which follows

Patient            :Rosalind Hinds                     Age       :6 days

Next of kin     :Genette Keating (Mother).    Date of birth   :22 April 2011

Discharge Date          :28 April 2011             Diagnosis        :Low birth weight & opioid dependence

Family            :Will live with mother at maternal grandmother’s house

Background   :Mother (22 years) heroin dependent 2 yrs

Mother, single and recently worked as a sex worker

Estranged from father of Rosalind as alleged domestic violence towards her during pregnancy

Genette’s mother supportive First child;  Department of Community Services involved but approve discharge living situation as long as with grandmother

Medical History and Medications: See Dr’s notes (to be forwarded)

Management and Progress during Hospitalisation:

Both mother and baby completed heroin withdrawal without complications Baby 2.0kg at birth; 2.3kg 28/4/11

Bottle feeding erratically? ↓ appetite Poor bonding between mother and baby. Genette often needs prompting to care for baby. Drug and alcohol team involved in managing Genette’s ongoing addiction issue.

Discharge plan: Daily visits until pt stable weight and feeding stable Ensure safe environment for baby and update Department of Community Services if risks present Monitor mother’s coping and psychosocial state Educate mother and grandmother on infant care.  Liaise with drug and alcohol team to provide integrated support for mother to decrease risk of heroin use.

Writing task: You are the Charge Nurse on the maternity ward where Rosalind Hinds was born and need to write a letter to the local community midwifery team outlining relevant information and requesting discharge follow-up. Address the letter to Maitland Maternal and Child Health Centre, Maitland

Submit your OET letters for correction: (for a minimal fee)
https://goltc.in/oet-writing-correction/