OET Rx (Student Pre-Class)

Lesson 10: Writing Basic Case Notes

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Course Progress

Overall Progress Lesson 10 of 100

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Part 1: Lesson Objectives

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

Understand the legal and clinical importance of accurate case notes.
Structure clinical notes using the SOAP (Subjective, Objective, Assessment, Plan) framework.
Use standard medical abbreviations correctly.
Write concise, objective, and legible patient records.

Lesson Video

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This video will be available for the offline course version.

Part 2: Vocabulary & Examples

Study the words, their pronunciations, Persian translations, and example sentences to understand how they are used in context.

General Vocabulary

drug /drʌɡ/:

دارو

It is your professional duty to document every drug administered to the patient.

due to /djuː tuː/:

به دلیل

The patient was admitted due to severe dehydration, which was a direct effect of the continuous vomiting.

during /ˈdʒʊərɪŋ/:

در طول

During the examination, I noted that the patient's abdomen was tender to the touch.

duty /ˈdjuːti/:

وظیفه

As a doctor, you have a legal and ethical duty to maintain clear and accurate medical records for each patient.

each /iːtʃ/:

هر

Each entry in the case notes must be signed and dated at the time of writing.

early /ˈɜːrli/:

زود

An early and accurate documentation of symptoms can be crucial for reaching the correct diagnosis.

easily /ˈiːzəli/:

به آسانی

Your notes should be written so that another colleague can easily understand the patient's current situation.

easy /ˈiːzi/:

آسان

Using a structured format like SOAP notes makes it easy to follow the clinician's thought process.

effect /ɪˈfekt/:

تأثیر

The positive effect of the treatment was documented in the progress notes.

effective /ɪˈfektɪv/:

موثر

For case notes to be effective, they must be concise and contain only relevant clinical information.

effort /ˈefət/:

تلاش

A conscious effort is required to write objective notes and avoid personal judgments.

element /ˈelɪmənt/:

عنصر

A key element of the "Plan" section is documenting the advice given to the patient.

emergency /ɪˈmɜːrdʒənsi/:

اورژانس

In an emergency situation, the admitting notes provide critical information for the entire team.

emphasis /ˈemfəsɪs/:

تأکید

There is a strong emphasis in modern medicine on documenting the shared decision-making process.

emphasize /ˈemfəsaɪz/:

تأکید کردن

I must emphasize the importance of dating every single entry you make in the patient's chart.

ensure /ɪnˈʃʊər/:

اطمینان حاصل کردن

Please ensure your handwriting is legible to avoid any potential medication errors.

Medical Vocabulary

Abbreviation /əˌbriːviˈeɪʃn/:

مخفف

Using standard medical abbreviations is effective, but you must avoid ambiguous or unofficial ones.

Assessment /əˈsesmənt/:

ارزیابی

The assessment part of your SOAP note should contain your primary diagnosis or differential diagnoses.

Chronological /ˌkrɒnəˈlɒdʒɪkl/:

زمان‌بندی شده

Case notes must be written in chronological order to accurately reflect the patient's journey.

Concise /kənˈsaɪs/:

مختصر

A good medical record is concise; it includes all necessary data without unnecessary words.

Legible /ˈledʒəbl/:

خوانا

If your handwriting is not legible, it is safer to type your notes to prevent serious errors.

Objective /əbˈdʒektɪv/:

عینی

The objective section contains your findings from the physical examination, such as vital signs and test results.

Plan /plæn/:

برنامه

The plan outlines the next steps, including further tests, new medications, referrals, and patient education.

Sign (v.) /saɪn/:

امضا کردن

You must sign and add your professional title to every entry you make in the patient's record.

SOAP notes /soʊp noʊts/:

یادداشت‌های SOAP

Using the SOAP notes format ensures that all critical elements of the consultation are documented effectively.

Subjective /səbˈdʒektɪv/:

ذهنی

The subjective section documents the patient's story in their own words, including their chief complaint and history.

Part 3: Pre-Class Practice Tests

Reading Task (Interdisciplinary Context: Physiotherapy):

Excerpt from "The Chartered Society of Physiotherapy - Code of Practice"

The legal and professional duty to maintain accurate patient records cannot be over-emphasized. Each entry serves as a chronological record of the assessment, diagnosis, and treatment provided. These notes ensure continuity of care, as another physiotherapist can easily understand the case and continue effective treatment. From a legal standpoint, case notes provide evidence of the care delivered. An entry that is not signed or dated, or is not legible, can be challenged. An effective note is objective and concise. It should document the subjective reports from the patient, the objective findings from your physical assessment, and a clear plan of action. A conscious effort must be made to avoid abbreviations that are not universally understood.

Question: According to the text, what is a primary legal reason for maintaining high-quality case notes?

Listening Task (Part A Simulation):

Scenario: You will hear a junior doctor dictating a brief admission note for a patient.

0:00

Task: Complete the notes below. Write one or two words for each gap.

Admission Note

Patient: John Williams

Presenting Complaint: (1)

Onset: Sudden, this morning, (2) breakfast.

Objective Findings:

Tenderness and guarding in the (3) .
Temperature: 38.5 degrees Celsius.

Initial Plan:

Admit for observation.
IV (4) .
Urgent (5) review.

Part 4: Answer Key for Pre-Class Work

Reading Answer: b) To provide evidence of the care that was delivered.

Listening Answers: (1) Abdominal pain, (2) after, (3) right lower quadrant, (4) fluids, (5) surgical

Part 5: In-Class Preparation

Be prepared to discuss the vocabulary and practice the following tasks in class.

Speaking Task: OET Role-Play Card (Medicine)

Setting: Hospital Ward, during a ward round.
Context: You are a junior doctor presenting a new patient to your senior consultant. The patient is a 65-year-old man admitted overnight with community-acquired pneumonia.
Task: Structure your verbal handover using the SOAP format.
S (Subjective): Briefly state who the patient is and what they complained of.
O (Objective): State the key findings from your examination and initial tests.
A (Assessment): State your diagnosis.
P (Plan): State the current treatment plan.

Writing Task:

You are the doctor from the speaking scenario. Based on a short vignette provided below, write a concise set of SOAP notes for a different patient.
Vignette: A 25-year-old female student comes to your clinic. She tells you she has had a painful, burning sensation when urinating for the past two days. She has also been feeling the need to urinate more frequently. She has no fever. A urine dipstick test you perform in the clinic is positive for nitrites and leukocytes. You diagnose a simple urinary tract infection (UTI). You prescribe a 3-day course of antibiotics and advise her to drink plenty of water.

Proceed to Lesson 11

OET Rx

In this lesson, you will be able to: