Ms Maria Dicoccio
Receiving Nurse
Proudhurst Mental Health Home
231Brightfield Avenue
Proudhurst
18 March 2018
Dear Ms Dicoccio,
Re: Ms Bethany Tailor, 35years
Ms Tailor requires follow up care and monitoring following discharge from our care today. She has been diagnosed with schizophrenia.
Good introduction
Better if you have written as decompensated schizophrenia.
1)Ms Tailor got admitted on the 1st of this month in a/an agitated and aggressive stage. Also, she has delusion, auditory, visual hallucinations along with thought blocking and latency with internal stimuli response. During hospitalization, her medication commenced on risperidone 4gram (2)which needs to be continue /continued every night. (Stop here)During subsequent days, she made a good recovery evidenced with minimal symptoms. Currently, she is able to focus on activities of daily living.
1]Is the case note says like that?
She was admitted with complaints of auditory and visual hallucinations along with delusions. She had agitation and aggressive behavioural problems together with thought blocking and latency with internal stimuli response.
While writing paragraph keep in mind that better to write one idea in one paragraph.
(2)and an additional dose of 1 milligram to be given in case of agitation and psychosis.
Ms Tailor is unemployed and depend on disability allowances. She has a history of polysubstance abuse mainly on coccaine and alcohol. Apart from these, she has a past medical history of hypertension secondary to fibro muscular(fibromuscular) dysplasia and she is on Levothyroxine 88mcg for primary hypothyroidism.
Except from the highlighted sentence, other details are not relevant.
All current details of the patient are very important
In view of the above, it would be greatly appreciated if you could ensure Ms Tailor's medication compliance and provide an arrangements for behavioral/behavioural therapy. Also, observe for objective signs of psychosis and resperidone 1 milligram to be give/given in case of agitation and psychosis.
An arrangement or arrangements
Please feel free to contact me if you need further information regarding Ms Tailor.
Yours sincerely,
Registered Nurse
Interpret your case note and organise it
Good starting but you have missed a lot of important points
Best wishes !!!!!!
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