WRITING TEST

Time allowed

Reading Time: 05 Minutes

Writing: 40 Minutes

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

CASE NOTES

Ms. Amy Vineyard is a patient in your care at the St Kilda Women’s Refuge Centre. She is 6 weeks pregnant with her first child. She presented two days ago, requesting help for her substance abuse problems. She reports a desire to reduce or cease her alcohol consumption and a desire to reduce a cease her drug use. No desire has been indicated to decrease or stop cigarette use. She now wishes to be discharged but will require ongoing support throughout her pregnancy.

Discharge summary

 Name: Ms. Amy Vineyard 

Age: 21 

Admission: 6/1/09 

Diagnosis: pregnant substance abuse

Discharge: 8/1/09 

Plan: 

• Community mental Health Nursing required daily next 2 weeks minimum. 
• Pt wishes to continue living with a friend on her sofa. 
• Psychiatric support needed for depression. 
• Methadone program Alcoholics Anonymous meetings 
• 1 Trimester Ultrasound at 2 weeks; 
• maternal health clinic appointment needed.

 

Reason for admission: 

• Patient. Self-admitted due to concern about pregnancy. Confirmed pregnancy test the days before (5/1/09) 
• Reported pain in lower back 
• weight loss (6kg over 2 months) 
• some memory loss 
• tingling in feet, difficulty sleeping, excessive worry and hallucinations 
• feeling depressed-history of depression 
• no pain in hips or joints 
• no decrease in appetite 
• no double vision

Treatment 

• pt. monitored and blood tests for HIV/AIDS and STDs 
• counselled re nutrition and pregnancy 
• counselled re HIV/AIDS and STDs risk 
• discussed possibility of rehabilitation clinic for ‘driving out’

Lifestyle: 

• Nicotine daily 30-40 cigarettes 
• started smoking at 15 y. o. 
• Drugs used cannabis, amphetamines, cocaine, heroin 
• started all above at 16 y. o. 
• injects heroin, occasionally shares infecting equipment 
• Alcohol 8 units/day __ max. units/day- 15 
• started drinking at 16 y. o. 
• lives with a friend, Sophie, on her sofa. 
• no contact with parents

History: 

• suicidal thoughts, self-harm in past 
• never seen a psychiatrist

Writing Task 

Using the notes, write a letter about Ms. Vineyard’s situation and history to new community health nurse. Address your letter to Ms. Lucy 8an, Registered Nurse, Community Health Centre, St Kilda.

In your answer:

• Expand the relevant notes into complete sentences
• Do not use note form
• Use letter format

The body of the letter should be approximately 180-200 words.