Patient History: Robin Williams 42-year-old man
Admitted to hospital for endoscopic removal of gallstones Admitted 22 May 2005
Discharged 24 May 2005
Today’s date: 25 May 2005

Social History: Married with two children 3,6
Policeman, works shifts at night
Wife away on business overseas for one week No family in Victoria

Nursing Notes: Routine post-operative recovery
Walking normally
Minimal pain-relieved with 3x Panadol daily Wound healed
Ultrasound showed operation successful

Discharge Plan: Rest for one week
No heavy lifting
Observe wound for infection. Council childcare for one week

Writing Task
Using the information in the case notes, write a letter of referral to Dr. Phillip Adams, 399 Bourke St, Melbourne, 3000, who will provide follow up care in this case.

Sample answer by Lifestyle Training Centre

Dr. Phillip Adams
399 Bourke St,
Melbourne, 3000

Dear Dr Adams,

Re: Mr Robin Williams, aged 42 years.

I am writing to refer Mr Williams, who requires follow-up care and management. He is currently recuperating from an endoscopic removal of gallstones.

Yesterday, Mr Williams was discharged after a smooth post-operative recovery as confirmed by the ultrasound. His wound was healed, and he ambulates well. He is advised to take Panadol, three times a day, to manage his minimal pain.

Mr Williams is a policeman and works night shifts. He is married and has two kids of 3 and 6 years of age. Mrs Williams is currently overseas on a business trip. They have no family in Victoria.

Based on the above, please provide care for Mr Williams. He needs to rest for one more week and must avoid heavy lifting. As the parents are not in a position to help, kindly arrange for them childcare for a week. If you have any queries, please do not hesitate to contact me.

Yours sincerely,
Registered nurse.