We have all seen how some case notes in the OET writing sub-test seem to have a LOT of information on them. Sometimes, a patient has had multiple visits to a GP with changes made to dosages of medicines or a progression of symptoms evidenced over various visits.
How can we summarise?
The question is, how can we summarise all of this into neat paragraphs? How much information should we include? Should we detail every single visit and every single change made?
These are questions that I'm sure are going through a lot of your minds, and Tharushi, one of my YouTube students actually got in touch to ask me for help on this, so let me try to offer you some guidance.
What is the easiest way to decide what to include in your OET letter?
The easiest way to decide what to include is to put yourself in the shoes of the reader. Imagine you are the consultant, or specialist, or health care practitioner who is going to receive this letter about this patient. What would you want to know?
Do you have time to read about every single little change that has happened to this patient? Probably not, right? It's probably not even relevant. All you want are the highlights - the most significant changes and their results. You then need details of what you have to do next etc, and this would come after the summary.
How many words should I write in my OET letter?
The other thing to remember is the guidance on word count for which the OET says that in the OET writing test you should write between 180 - 200 words. There is a reason for this. You should be able to summarise all the main points within these two figures.
However, don't stress if you end up writing 177 or 205 words, though. Your number of words won't be counted as such, but the number of points you include will be, and these should all be relevant and efficient to read.
This, therefore, means that some clever summarisation of events needs to be done.
Let's look at an example together:
Patient Name: Sarah Johnson DOB: 09/12/1982 Gender: Female
Visit 1:
Date: 01/03/2022
Presented with persistent joint pain and swelling in the knees and wrists for the past month.
Medical History:
No significant medical history reported. No known allergies.
Assessment:
Subjective: bilateral knee and wrist joint effusion; limited ROM; tenderness on palpation. No signs of inflammation elsewhere.
Plan:
Complete blood count (CBC) and rheumatoid factor (RF) ordered.
Analgesic: ibuprofen (2 x 200 mg up to four times a day).
Advised rest and application of ice packs to affected joints.
Visit 2:
Date: 29/06/2023
Patient returned with persistent joint pain and increasing difficulty in performing daily activities.
Blood test results indicate elevated RF levels (22 IU/ml). Increased joint effusion in both knees and wrists. Patient reports morning stiffness lasting more than an hour.
Plan:
Referral to rheumatologist for further evaluation and diagnosis.
Prescribed oral corticosteroids (Prednisone 2mg x 1 per day in mornings) to reduce inflammation.
Referral to physiotherapy sessions to improve joint mobility.
How can we divide the information?
Let's think about how we can divide this information. Should we write one paragraph about the first visit and then one about the second? Or should we divide it by presenting concerns and then treatment?
The way we can decide is by thinking of the following:
"Will knowing about the initial visit help?" - Yes, in some ways. We should get an indication of time to see how fast or slowly things are changing.
"Will knowing about the initial observations help?" - Yes, because again, it will help us identify any changes.
"Will knowing about initial prescriptions help?" - Probably not, because they are fairly standard and obviously the new prescription replaces the old one.
"Will knowing about the second visit help?" - Yes, especially in the context of change.
What are the main points?
From these questions, we can see that the main points should centre around change; the progression (deterioration) of the condition over time.
This should be evidenced with observations, test results, and patient reports.
Here's an idea of how you can combine the two visits
This would be your first body paragraph and come after your opening in which you introduce the patient, her condition, and what you hope the reader can do.
Ms. Johnson has been experiencing persistent joint pain and swelling in her knees and wrists for the past three months. Blood tests taken after her first visit in March revealed elevated RF levels (22 IU/ml), and in an appointment with me today, Ms Johnson reported persistent joint pain and increasing difficulty in performing daily activities, together with morning stiffness lasting more than an hour. In comparison with my first examination Ms Johnson today also displayed increased joint effusion in both knees and wrists.
Let's break this paragraph down
First of all, to save you counting, it's 99 words long!
We start off by explaining the patient's condition = persistent joint pain and swelling in her knees and wrists
And give an indication of time = for the past three months
We mention the first visit in combination with the test results that were ordered on that visit (so this is a nice way to summarise both ideas) = Blood tests taken after her first visit, in March, revealed elevated RF levels (22 IU/ml)
We then go on to describe the report by the patient herself and how this is affecting her. Again, we give an indication of time to make sure that the time line is nice and clear = Ms Johnson reported persistent joint pain and increasing difficulty in performing daily activities, together with morning stiffness lasting more than an hour. in an appointment with me today, Ms Johnson reported persistent joint pain and increasing difficulty in performing daily activities, together with morning stiffness lasting more than an hour.
The final part of this paragraph looks at your own observations and compares those to the past ones = In comparison with my first examination Ms Johnson today also displayed increased joint effusion in both knees and wrists.
There is no need to detail each visit separately
As you can see, there's no need to detail each of the patient's visits separately if it's more efficient and makes more sense to combine ideas.
We would then use the remaining 90 words or so of our letter to write the opening, and then after this body paragraph, to perhaps talk the discharge plan, and other medical history that's important and applicable. Finally, we need a line or two to re-state the purpose and end professionally.
I've not included those details here today, because I just wanted to focus on summarising visits, but I hope this gives you an idea of how to write a body paragraph.
What you should remember when you need to summarise multiple visits by a patient and a change in condition
Here are the main things you should remember:
Don't necessarily think you need to summarise each visit in turn. Sometimes, this might make sense, but at other times, like above, it might be better to summarise across the two visits by theme (test results; patient's concerns; your observations).
Think about what you would want to know as a reader, and basically, write that!
Don't forget to make the timeline clear.
I hope this helps. If you have questions, please feel free to get in touch, and if you'd like a discount on our pre-recorded on-demand courses, check out the links below.
To join our mailing list for a regular dose of all things OET, please click on this link:
https://mailchi.mp/ca7d74488740/yourregulardoseofoet
To get a discount on our pre-recorded on-demand video courses, please click on the links below:
Lesson created by: Bose Learning www.boselearning.co.uk A Premium Preparation Provider of the OET
Comments