Case note 31/07/2020
Letter 29
I have a doubt with the discharged date. Consider it as 15 January 2018
The Director
Community Child Health Service
41 Vulture Street
West End
Brisbane 4101
15 September 2012
Dear Sir/Madam,
Re: Nicola Boyle and her newborn baby
DOB: 08 August 1998,11 January 2018
Ms Nicola Boyle is a post natal [postnatal is a one word]mother. She and her baby require home visit[ a home visit] to provide advice and assistance. The mother and baby was/were discharged.
Introduction is not up to te mark
It would be fine writing “they are being discharged today”
Ms Nicole underwent an emergency cesarean section from our hospital and gave birth to her first baby on 11 January,2018. They require your advice and assistance at home as she has some child care issues.
Ms Boyle was admitted on 10 January 2018 and has undergone emergency cesarean section due to fetal distress and failure to progress. Consequently, she gave birth to a male baby with body weight [ a birth weight]of 4.3kg. During hospitalization, she had postpartum haemorrhage. On the subsequent day, her haemoglobin level was found to be as 90g/L; therefore, fetfol(spelling) and vitamin c were commenced for her. She has initiated to breastfeed which she wants to change to bottle feed. She has no confidence in breastfeeding, bathing and caring for the baby. Additionally, she has verbalized about offering the baby for adoption.
Current birth weight should be written
Apgar score changes should be mentioned
Ms Boyle is single. She has no contact with her family members and the father of the child. She is a sole parent benefits receiver. She feels isolated and insecure.
It would be greatly appreciated if you could organise a home visit to provide assistance for Ms Boyle and her baby. Her contact details are enclosed. Home address should be mentioned as given in the case note.
Yours sincerely, [faithfully]
Registered Nurse
Overall presentation is not bad
However paragraphing could have been done better
One paragraph which explains regarding mother and one for child.
Good Luck!!!
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