Session 4 – Hospital Instructions & Notes

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Level: B1 (OET Medicine)
Duration: 50 minutes
Skills: Reading + Writing
Theme: Ward instructions & care plans
Real-life Scenario: A nurse preparing handover notes at the end of a hospital shift

Objectives (new)

By the end of this session, you will be able to:

  • ✅ Read and extract info from ward instructions and hospital memos (OET Reading Part B style).
  • ✅ Write a clear, structured nursing/doctor handover note using passive voice.

Objectives (reviewed)

  • ✅ Use imperatives and modals to give advice (Session 2).
  • ✅ Explain medical information in simple, patient-friendly language (Session 3).
  • ✅ Describe symptoms using terms like chronic, persistent, and acute (Session 1).

ward – hospital area where patients stay
Example: The patient was kept in the surgical ward overnight.

shift – work period for hospital staff
Example: Vital signs were recorded during the night shift.

admission – when a patient enters hospital
Example: She was admitted yesterday for observation.

discharge – when a patient leaves hospital
Example: The discharge papers were prepared by the doctor.

observation chart – sheet for recording vital signs
Example: The blood pressure was written on the observation chart.

mobility – ability to move/walk
Example: Reduced mobility was noted in the care plan.

referral form – paper sent to another doctor/service
Example: A referral form was completed for physiotherapy.

care plan – written plan for patient’s treatment
Example: Daily physio sessions were included in the care plan.

vital signs – key body measures (BP, pulse, temp)
Example: The vital signs were checked every 4 hours.

Recap: What can you now do after Sessions 1–3?

Describe symptoms, give lifestyle advice, and explain tests.

How does the staff receive instructions in a hospital?

Reading

Check the following hospital notice. Who writes this? Who reads it? What type of language is used?

Hospital Notice: Vital Signs Monitoring and Escalation

Scope: All inpatient wards
Effective: Immediately

  1. Frequency
    Vital signs (temperature, pulse, respiration, blood pressure, and oxygen saturation where applicable) must be recorded at least every four (4) hours unless a doctor has documented a different schedule in the care plan.
  2. Documentation
    All readings must be entered clearly and legibly on the Observation Chart, with date, time, and staff signature/ID for each set.
  3. Abnormal Readings
    If any parameter is outside the normal range, recheck within 15 minutes. If the abnormality persists or the patient’s condition deteriorates, notify the responsible doctor immediately and escalate via the early warning system (MEWS/NEWS as per hospital policy).
  4. Oxygen/Interventions
    If oxygen therapy or other interventions are started, document the indication, settings, and patient response on the Observation Chart and in the nursing notes.
  5. Handover
    Highlight significant changes and any pending reviews during shift handover.

Accountability: Nurse-in-charge of shift
Reviewed by: Infection Control & Patient Safety Committee (annual review)

Read this handover note. Highlight imperative verbs: Monitor, Record, Refer, Discharge. Note and circle key terms.

Nursing Handover Note – Ward 3B
Patient: Mr. John Smith, 67 yrs (admitted with pneumonia)
Date/Time: 22 Aug 2025, 07:00 hrs

  • Observations: Temp 37.8°C, BP 138/84, HR 92, SpO₂ 95% RA
  • Plan: Monitor vital signs every 4 hrs and record on obs chart.
  • If temp ≥ 38.5°C or SpO₂ ≤ 92%, notify MO immediately.
  • Patient mobilising with assistance; maintain IV antibiotics as charted.
  • Discharge planning: referral form sent to physiotherapy; awaiting review.

RN Signature: ____________________

Writing

Example handover: “Patient admitted at 07:00, stable vital signs, mobility limited, referral to physio sent. Discharge planned for tomorrow.”

Structure: Admission → Current status → Actions → Next steps.

Read and answer

If a patient’s vital signs fall outside the normal range, staff must:
A. notify the next shift staff.
B. record them on the observation chart and monitor closely.
C. repeat the measurement, document it, and notify the doctor.

Ward Observation Policy

All admitted patients must have their vital signs (temperature, pulse, respiration, and blood pressure) checked and recorded on the observation chart every four hours unless otherwise directed by a doctor.
If any results are abnormal, staff should repeat the measurement within 15 minutes. If the abnormality persists, the responsible doctor must be notified immediately.
Failure to report significant changes in a patient’s condition during your shift may delay treatment and compromise patient safety.

Read the following case and write a handover note

Ward: 2A – Medical
Patient: Mrs. Helen Brown, 72 yrs
Admission: 21 Aug 2025, 15:00 hrs – admitted with chronic heart failure
Observation Chart:

  • Temp 36.9°C, BP 150/90, HR 88, SpO₂ 94% on RA
    Mobility: Needs walking frame, short distances only
    Care Plan:
  • Monitor vital signs every 4 hrs
  • Low-salt diet, fluid restriction
  • Continue prescribed medications (diuretics)
    Referral: Cardiology team review requested
    Discharge: Expected in 2–3 days, home with community nurse follow-up

Complete the handover note

Patient ….. yesterday with …….. Current ……… stable. Mobility limited, walking frame required. …… includes fluid restriction, low-salt diet, and 4-hourly observations. ………. to cardiology sent; awaiting review. ………… in 2–3 days.

Read the case

Ward: 5C – Surgical
Patient: Mr. Daniel Lee, 54 yrs
Admission: 23 Aug 2025, 10:30 hrs – admitted for benign prostate enlargement
Observation Chart: Temp 37.1°C, BP 132/80, HR 84, SpO₂ 97% RA
Mobility: Independent, walks unassisted
Care Plan:

  • Monitor vital signs 4-hourly
  • Encourage oral fluids
  • Pain management with paracetamol as charted
    Referral: Urology follow-up arranged
    Discharge: Planned for tomorrow morning if stable

Write a handover note:

…………………………………………………………….

Can-do Checklist

☑ Used passive voice to highlight the object.

☑ Wrote a short, clear handover note.

☑ Recycled at least 5 glossary words.

📤 Create your own lifestyle questionnaire and ask friends to answer it.

🎥 Write a patient advice note with recommendations for each friend.


Write a handover note for every case in the lesson.

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