To build a good OET Discharge Summary, keep the following essential steps in mind:

1. Read the Case Notes Carefully

Read and locate important information in the first 5 minutes.

Highlight key information such as symptoms, medical history, and follow-up.

Eliminate the redundant information to make it concise.

2. Organize Your Letter Correctly
Your discharge summary must be logically well-organized as follows:

A. Introduction (Purpose of the Letter)
Simply put the purpose of the letter in one or two sentences.
Example:
I am reporting a discharge summary for Mr. John Doe, a 67-year-old male who was seen at St. Mary’s Hospital on March 10, 2024, with a myocardial infarction. He is stable now and should be seen by his primary care physician.

B. Patient Background and Admission Information
Give a concise overview of the patient’s admission presentation.
Provide pertinent medical history and symptoms.
Example:
Mr. Doe is a patient with Type 2 diabetes and hypertension history. He experienced severe chest pain and dyspnea, so he was admitted urgently for cardiac evaluation.

C. Treatment Provided
Summarize the major interventions during hospitalization.
List medications, surgeries, or therapy.
Example:
He received a coronary angioplasty and was stabilized on medications such as aspirin, beta-blockers, and statins during his stay.

D. Condition at Discharge
Describe the patient’s current status and readiness for discharge.
Example:
Mr. Doe is improving significantly. He is hemodynamically stable and does not need inpatient status.

E. Instructions and Recommendations for Follow-Up
Express post-discharge instructions clearly.
Provide medication schedules, lifestyle recommendations, and follow-up visit needs.
Example:
He should follow medications as instructed and follow a low-sodium diet. He will have a two-week follow-up visit for re-evaluation.

3. Professional and Formal in Tone
Employ concise, professional language appropriate for healthcare communication.
Do not use excessive jargon and very technical language.

4. Be Grammatically Correct and Proper in Sentence Construction
Utilize short sentences, which are grammatically sound and unambiguous.
Passive voice is used where necessary (e.g., “The patient was treated with.”).
Use correct tense (past tense for advice, present/future tense for history).

5. Preserve Logical Order and Coherence
Use linking words (e.g., therefore, however, consequently) to link ideas logically.
Organize information in a logical manner so that it is readable and comprehensible.