TASK – 69     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 : Nil                           Medications. NIL

Social Truck Driver   

History/Supports Lives with her 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        

BCC – 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.

View sample answer by Lifestyle Training Centre

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