Occupational Therapy · Discharge letter · Intermediate

OET Case Notes: OT Discharge to Aged Care Facility (Intermediate)

An inpatient OT discharges a 74-year-old to a residential aged care facility following right hip replacement. The intermediate challenge: selecting which functional details matter to a receiving OT, summarising equipment in place, and giving a realistic ADL picture without over-loading the letter with hospital detail.

Letter type

Discharge

Write to

Aged Care Facility OT

Target length

200–230 words

The case notes

Patient: Mr Kenneth Lowe, 74 years old

Diagnosis: Right total hip replacement (posterior approach) — Day 7 post-op

Discharge destination: Rosewood Gardens Residential Aged Care; home deemed unsuitable

Functional status: Requires assistance with lower limb dressing and showering; independent upper body; transfers with standby assistance using a gutter frame

Cognitive status: Mild cognitive impairment (MMSE 22/30); follows two-step instructions reliably

Hip precautions: Posterior hip precautions for 12 weeks — no flexion >90°, no internal rotation or adduction

Equipment issued: Raised toilet seat (10 cm), long-handled shoe horn and sock aid, gutter frame

ADL goals: Progress toward independent showering and dressing within 6 weeks if no complications

Next of kin: Daughter aware of placement and OT plan

Writing task

Write a discharge letter to the receiving occupational therapist at Rosewood Gardens Aged Care, summarising Mr Lowe's functional status, equipment, hip precautions, and your recommendations for ongoing OT support.

What to include, what to cut

The hardest mark to win is selection. The same case notes contain decision-relevant facts and distractors. Here is what an examiner expects to see in a Grade B letter for this scenario, and what should be left out.

Include

  • Hip precautions and their 12-week duration

    This is a safety-critical handover item. If the receiving OT is not informed, the precautions cannot be enforced and the patient risks dislocation.

  • Functional status at ADL level — what he can and cannot do independently

    The receiving OT needs a functional baseline to set goals. Diagnosis alone is not enough; function at discharge drives the care plan.

  • Equipment issued and the specific items

    Avoiding duplication and ensuring compatibility with the new environment depends on the receiving team knowing exactly what equipment is in place.

Leave out

  • The surgical approach in detail

    The precautions matter to the receiving OT, not the operative technique. Mention the approach as context; explaining it is not your role and wastes words.

  • MMSE scoring methodology

    State the score and the practical implication (two-step instructions reliably followed). The receiving team does not need a dementia lesson.

Criterion in focus · Content

Content marks are won by selecting the right clinical details for the recipient, not by including everything. A receiving OT needs function, precautions, and equipment. They do not need the anaesthetic type, the ward number, or the full medication list. Ask: 'would this OT act differently if this line were missing?' If no, cut it.

Now write the letter — and find out what is blocking your Grade B

Write a 200–230 words discharge letter from these notes, paste it into the free checker for an instant read, then submit it for a human grade against all six criteria. Dr Mariam's team returns line-by-line feedback, from $12.

Questions about this case note

Should I include the patient's medication list in an OT discharge letter?
No. Medications are the domain of the nursing handover and medical discharge summary. Mention medication only if it directly affects OT management — for example, anticoagulation affecting positioning during wound care.
How do I handle cognitive impairment in the letter?
State the score and then the functional implication for the receiving team: what the patient can follow, what they cannot, and any safety behaviours to note. A number alone (MMSE 22) means little without that context.

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