Evaluation 9
Evaluation 9
Mr Jones works as a forklift driver in a warehouse, which requires prolonged sitting and
occasional heavy lifting.
is a patient of mine since. Initially, on 21/03/2015, he Mr Jones visited me after hurting his
back while lifting a heavy object off the ground. Fortunately, no disc problems were indicated
on his x-ray. Therefore, He has been relevant medications were prescribed and has been he
was advised to attend regular physiotherapy sessions Since his first appointment, he has been
advised and take off from work.
Subsequently, Mr Jones presented with persistent back pain. He had been progressing well;
however, he had pain in his back while moving. Consequently, the dosage of Naproxen was
increased, and further extension of leave was recommended.
Today, Mr Jones visited for follow-up. He is still experiencing pain and stiffness in his back.
Although his range of motion has increased; however, but his back pain exaggerates after
sitting or lying down for more than 20-30 minutes. In addition, he feels fatigued after walking
about 30 minutes in a day. Due to the illness and long stay at home, Mr Jone he is feeling
demotivated and anxious and wants to return back to his job. I have allowed him. Therefore,
he has been advised to rejoin his work with regular breaks and prohibition of his heavy lifting.
In the view of the above, your assessment of Mr Jones’ workplace and further advice on duties
which he Mr. Jone can perform would be highly appreciated.
Content
Write the second name of the patient with Mr/Ms instead of the pronoun at the
beginning of each paragraph. If the patient is less than 16 years old, you only write the
first name without Mr/Ms. If pt is over 16 years old, write 2nd name with Mr/Ms (Mr
Jones).
Do not write Mr/Ms with the patient’s name in the reference (Re: Mr Barry Jones, 44-
year-old).
You must not mention the word (patient). Use pronoun like he/she or the name of pt
directly in the first line.
Improve your case note selection by focusing on presenting complaints of the patient’s
most recent visit and by keeping the recipient of the letter and his profession in mind (to
whom you are writing the letter).
Language: Use the correct form of a verb where required (Therefore, He has been
relevant medications were prescribed and has been he was advised to attend regular
physiotherapy sessions Since his first appointment, he has been advised and take off from
work).
Organisation and Layout: For this letter; Introduction > Patient’s personal details > Initial
visit para > Subsequent visit para > Today’s visit para > and > Closing
The underlined lines are written by you but placed incorrectly. Their underlining refers to
the place where they must be.