OET discharge letter after surgery: what to include for a post-operative patient
An OET discharge letter after surgery should tell the reader what operation the patient had and when, how they have recovered, and exactly what care continues at home: wound and suture care, pain relief, mobility, any drains or equipment, warning signs, and follow-up appointments. Leave out intraoperative detail and day-by-day ward progress unless it changes what the reader must do.
What makes a post-operative letter different
Many nursing case notes describe a patient going home or to another facility after an operation: a joint replacement, a bowel resection, a hernia repair, a caesarean section. The reader, usually a community nurse, practice nurse or GP, takes over aftercare. They do not need to know how the surgery went in the theatre; they need to know what to do next and what to look out for.
That shift in focus is the main selection decision. Ward notes often list each day's observations, pain scores and meals. Most of that shows that recovery was normal and can be summarised in one sentence.
What to include and what to leave out
| Usually include | Usually leave out |
|---|---|
| Procedure name and date | Anaesthetic type, theatre times, surgeon's technique |
| Overall recovery in one or two sentences | Daily observations that were normal |
| Complications that affect aftercare | Brief, resolved problems with no follow-up |
| Wound: site, closure (sutures, staples, glue), condition, dressing | Every dressing change in hospital |
| Pain relief at discharge and how well it works | Each dose given on the ward |
| Mobility, aids and weight-bearing instructions | Physiotherapy sessions in detail |
| Drains, catheters, stomas or equipment going home | Equipment removed before discharge, unless relevant |
| New or changed medications (antibiotics, anticoagulants) | Long-standing medications unchanged |
| Warning signs the reader should watch for | General post-operative advice the reader knows |
| Follow-up appointments, suture removal dates | Appointments with no role for the reader |
A paragraph plan
- Purpose: who the patient is, the operation and date, and that they are being discharged to the reader's care.
- Recovery so far: overall progress and any complication that matters.
- Current care needs: wound, pain, mobility, equipment, medications.
- Request and follow-up: what you want the reader to do, warning signs, appointment dates.
If the patient has important social factors (lives alone, carer needs support), place them where they explain a need, often in paragraph 3. See the social history guide.
Sentence patterns for post-operative letters
- "Mr Shah underwent a laparoscopic cholecystectomy on 3 March and is being discharged home today."
- "His recovery has been uneventful, and he is eating and drinking normally."
- "Her recovery was complicated by a urinary tract infection, which was treated with oral antibiotics; she has two days of the course remaining."
- "The wound is closed with staples, which are due for removal on 14 March."
- "He is able to walk independently with a walking stick and has been advised to bear full weight."
- "Please monitor for signs of wound infection, such as increasing redness, warmth or discharge."
Worked example (invented case)
Case summary (invented): Mrs Leila Haddad, 69, retired teacher. Right total knee replacement 8 May for osteoarthritis. Day 1: nausea, resolved with antiemetic. Day 2: mobilising with frame. Day 3: wound ooze, swab taken, negative; ooze stopped day 4. Discharge 13 May. Wound: 15 cm, clips, dry dressing, clips out day 12–14 (20–22 May). Pain: paracetamol 1 g four times daily and oxycodone 5 mg up to twice daily as needed; pain 3/10 on walking. Enoxaparin 40 mg subcut daily for 14 days (to 22 May); daughter taught to give injections. Walks 30 m with frame; stairs with supervision. Lives with husband (has limited mobility). Physiotherapy outpatient 16 May. Orthopaedic review 19 June. PMH: hypertension (amlodipine, unchanged), hypothyroidism (thyroxine, unchanged). Task: write to the community nurse.
Selection decisions:
- In: procedure and date; recovery uneventful (the nausea and negative swab can be dropped, or the ooze mentioned briefly because the reader watches the wound); clips and removal window; pain relief; enoxaparin and who gives it; mobility; husband's limited mobility (explains support need); physiotherapy and review dates.
- Out: day-by-day progress, nausea, amlodipine and thyroxine (unchanged and unrelated), her previous job.
Sample letter body:
Dear Community Nurse,
Re: Mrs Leila Haddad, aged 69
I am writing to refer Mrs Haddad, who underwent a right total knee replacement on 8 May and is being discharged home today, for wound care and post-operative support.
Her recovery has been satisfactory. A small amount of fluid leaked from the wound on the third day after surgery, but a swab was negative and the wound has been dry since.
Her 15 cm wound is closed with clips, which are due for removal between 20 and 22 May. Her pain is controlled with regular paracetamol and oxycodone when required. She is receiving daily enoxaparin injections until 22 May, which her daughter has been taught to give. She walks 30 metres with a frame but needs supervision on stairs, and her husband has limited mobility himself.
I would be grateful if you could remove her clips, check her wound and monitor her mobility at home. She has outpatient physiotherapy on 16 May and an orthopaedic review on 19 June.
Yours sincerely,
The letter is organised around what the reader does, not the order of events on the ward. For more on discharge structure, see the discharge and transfer letter guide, and for wound wording, the wound care guide.
Common mistakes
- Retelling the ward stay day by day. Summarise; the reader needs the outcome.
- Burying the dates. Clip removal and appointments should be easy to find, usually in the final paragraph.
- Listing all medications. Focus on new and changed drugs, as in the medications guide.
- Forgetting who does what. If a family member gives injections or the patient needs help, say so.
Practise it
Try a discharge case under time in practice, or upload a letter you have written to see an estimated grade, criterion marks and which case notes you included, missed or included unnecessarily.
Sources
This guide is medEmu's writing advice, not official OET guidance and not clinical advice; all patients, procedures and case notes are invented. The network used for this run could not reach oet.com, so no OET test facts are stated beyond the criterion names. For OET's official Writing information, see oet.com.