Four sets of case notes, four readers, and a marker that reads what you wrote.
The Writing page teaches the method on one nursing case. This page is the practice: four original cases, one each for medicine, physiotherapy, pharmacy and dentistry, each with the notes, the task line, a model letter I wrote and the selection decisions behind it. Write yours first, under the clock, then open the model, then have your letter read against the six criteria at the foot of the page.
How to use the page. Pick the case nearest your profession, but do the other three as well: the selection skill is the same whoever the reader is, and a physiotherapist who has written a pharmacist’s letter understands what “relevant to the reader” means better than one who has only written her own. Five minutes reading, forty writing, no notes open in another window. The model is folded shut on purpose; a letter compared with a model before it is written is a copy, not practice. The cases are invented and are language practice, not clinical guidance.
01Before each case
The three questions, in the reading time.
The method is on the Writing page in full. This is the version that fits on the back of your hand.
1
Who is reading, and what will they do next?
The task line, read first
A GP acts on medication and follow-up. A surgeon acts on findings and risk. A care-home manager acts on daily care. Everything in the notes is relevant or irrelevant to that action, and to nothing else.
Write the reader’s next action in four words before you read a line of the notes.
2
What must the reader be told?
The must-list, usually five to eight items
The event, the changes, the requests, the risks. If the reader would be wrong-footed without it, it is on the list. If the reader already knows it, it is not, however important it looks.
A GP knows the patient’s regular medication and allergies. A specialist does not.
3
What is the first sentence?
Patient, event, request, in one line
Purpose is a separate criterion, scored on the opening. The first sentence names why the letter exists; the paragraphs then follow the reader’s order of need, not the order of the notes.
“I am writing to…” is fine. “I am writing to inform you about the above patient” is not, because it says nothing.
02Medicine
Discharge letter: hospital doctor to GP.
The case notes
Patient: Mr Marek Nowak, 58 years old
Admitted: 3 September 2026, Coronary Care Unit, Riverside General Hospital
Discharge: 8 September 2026, home
Social history:
Lives with wife in a two-bedroom flat, second floor, lift working.
Long-distance lorry driver (holds a heavy goods vehicle licence). Self-employed.
Smoker, 15 cigarettes a day for 35 years. Alcohol: 4 to 6 pints at weekends.
No regular exercise. BMI 31.
Medical history:
Hypertension (diagnosed 2019), on amlodipine 5 mg daily, poorly adherent.
Type 2 diabetes (diagnosed 2023), diet-controlled, HbA1c 52 mmol/mol in June.
Father died of a heart attack aged 61.
No known drug allergies.
Presenting complaint:
Central chest pain for 2 hours while unloading, radiating to left arm, sweating.
ECG: ST depression in lateral leads. Troponin raised.
Diagnosis: non-ST-elevation myocardial infarction (NSTEMI).
Hospital course:
Coronary angiogram 4 September: 90% stenosis of the circumflex artery, treated with a drug-eluting stent. Other vessels: mild disease, no intervention.
Echocardiogram: ejection fraction 50%, mild inferolateral hypokinesia.
No further chest pain. Mobilising on the ward without symptoms.
Lipids: total cholesterol 6.4 mmol/L, LDL 4.2 mmol/L.
Blood pressure at discharge 142/88.
Wife attended the discharge discussion; both anxious about a second attack.
Medication on discharge:
Aspirin 75 mg daily (lifelong).
Ticagrelor 90 mg twice daily for 12 months (do not stop without cardiology advice).
Atorvastatin 80 mg at night.
Bisoprolol 2.5 mg daily; to be titrated upwards as blood pressure and heart rate allow.
Ramipril 2.5 mg daily; to be titrated upwards; check renal function and potassium in 1 to 2 weeks.
Amlodipine stopped.
Glyceryl trinitrate spray, as required; use explained.
Discharge plan:
Cardiac rehabilitation programme: referral made; first appointment in 2 to 3 weeks.
Smoking cessation: brief advice given, patient willing; nicotine replacement started on the ward; referral to the stop-smoking service made.
Driving: advised not to drive for at least 4 weeks and to inform the licensing authority; his HGV licence will need a separate assessment before he can return to work.
Cardiology clinic review in 8 weeks; repeat lipids at 3 months (target LDL below 1.8 mmol/L).
Diabetes: HbA1c and annual review due.
Writing task:
Using the information in the case notes, write a letter to Dr Helen Achterberg, GP, Bridge Street Surgery, informing her of Mr Nowak's admission and the follow-up you would like her to provide. Expand the relevant case notes into complete sentences. 180 to 200 words.
A model I wrote, at Grade B · 183 words · open after you have written yours
Dear Dr Achterberg,
Re: Mr Marek Nowak, aged 58
I am writing to inform you of Mr Nowak's admission with a non-ST-elevation myocardial infarction and to ask you to continue his follow-up after his discharge today.
He presented on 3 September with two hours of central chest pain. The ECG showed lateral ST depression and troponin was raised. Angiography revealed a 90% circumflex stenosis, which was treated with a drug-eluting stent. His ejection fraction is 50%.
He has been discharged on aspirin, ticagrelor for twelve months, atorvastatin 80 mg, bisoprolol 2.5 mg and ramipril 2.5 mg; amlodipine has been stopped. I would be grateful if you could check his renal function and potassium within two weeks and titrate the bisoprolol and ramipril as his blood pressure allows. It was 142/88 at discharge.
He has been referred to cardiac rehabilitation and to the stop-smoking service, and has been advised not to drive for four weeks; his HGV licence will need separate assessment. Cardiology will review him in eight weeks. His HbA1c and diabetes review are also due.
Yours sincerely,
Dr A. Patel
Cardiology Registrar
- Purpose The first sentence gives the diagnosis and the request. Dr Achterberg knows within one line that this is a discharge letter asking for follow-up.
- Must The event, the stent, the ejection fraction, every medication change, the blood test and the titration request, the driving advice and the two referrals. Each of these changes what the GP does in the next fortnight.
- Leave The flat and the lift, the father’s death, the weekend drinking, the BMI, the GTN spray explanation, the lipid figures and the three-month target. The GP knows his history; the lipid target belongs to the cardiology clinic that set it.
- May, kept The HGV licence, because the GP will be asked about fitness to work and needs to know an assessment is required. One clause, not a paragraph.
- Genre Doctor to doctor: abbreviations the reader uses daily (ECG, HbA1c) are fine; “NSTEMI” is written out once in full. Numbers are kept where the reader acts on them and dropped where they do not.
03Physiotherapy
Referral letter: physiotherapist to GP.
The case notes
Patient: Ms Priya Raman, 34 years old
Setting: Outpatient physiotherapy, Northgate Health Centre
Referred by: Dr Simon Yates, GP, on 21 July 2026
Social history:
Secondary school teacher (geography); full-time; stands most of the day.
Lives with partner; no children. Runs 5 km twice a week before the injury; stopped.
No smoking. Alcohol: occasional.
Medical history:
Asthma, mild, salbutamol inhaler as required.
No previous back problems. No relevant surgery.
Takes ibuprofen 400 mg three times daily and paracetamol; has been taking ibuprofen continuously for 8 weeks.
Presenting complaint (first appointment, 28 July):
Low back pain for 6 weeks after lifting boxes of exercise books; pain radiating to right buttock and calf; pins and needles in the right foot.
Pain 7/10 in the morning, 4/10 by midday. Worse sitting; eased by walking.
No bladder or bowel symptoms; no saddle numbness; no weakness on testing. Straight leg raise: right positive at 45 degrees.
Working diagnosis: lumbar disc irritation of the right L5/S1 nerve root. No red flags.
Treatment (6 sessions, 28 July to 8 September):
Education on posture and load; advice to keep moving; graded exercise programme (extension exercises, walking, core control); manual therapy to the lumbar spine.
Work: advised to alternate sitting and standing; a high stool obtained from the school.
Progress:
Back pain improved: 7/10 to 3/10 in the mornings. Sitting tolerance 15 minutes, now 45 minutes.
Leg symptoms improved for 4 weeks, then plateaued: calf pain 4/10 and pins and needles daily, unchanged for the last 3 sessions.
Straight leg raise now 60 degrees. Still no weakness, no change in reflexes, no bladder or bowel symptoms.
Sleeping better. Anxious about the leg symptoms; has been reading about surgery online.
Ran 2 km on 6 September without pain during the run; calf symptoms worse that evening.
Plan:
Continue home exercise programme; review in 4 weeks.
Recommend review of pain relief: continuous ibuprofen for 8 weeks; is a different approach appropriate?
If leg symptoms unchanged at next review, consider referral for a specialist spinal opinion.
Advised patient to contact GP or emergency services at once if new weakness, numbness in the saddle area, or any bladder or bowel change.
Writing task:
Using the information in the case notes, write a letter to Dr Simon Yates, GP, Northgate Health Centre, updating him on Ms Raman's progress and requesting a review of her pain relief. Expand the relevant case notes into complete sentences. 180 to 200 words.
A model I wrote, at Grade B · 200 words · open after you have written yours
Dear Dr Yates,
Re: Ms Priya Raman, aged 34
Thank you for referring Ms Raman with low back pain and right-sided leg symptoms. I am writing to update you on her progress after six sessions and to ask you to review her pain relief.
Her back pain has improved: morning pain has fallen from 7/10 to 3/10, and she can now sit for forty-five minutes rather than fifteen. Her leg symptoms improved for the first four weeks but have since plateaued, with daily calf pain and pins and needles in the right foot unchanged over the last three sessions. Straight leg raise has improved from 45 to 60 degrees, and there is still no weakness, no change in reflexes and no bladder or bowel disturbance.
She has been taking ibuprofen 400 mg three times daily continuously for eight weeks, and I would be grateful if you could review whether this remains appropriate. I will see her again in four weeks; if the leg symptoms are unchanged, I would suggest considering a specialist spinal opinion.
She has been advised to contact you or emergency services immediately if she develops weakness, saddle numbness or any bladder or bowel change.
Yours sincerely,
Physiotherapist
- Purpose Two purposes, both in the first paragraph: an update and a request. The GP knows what to do with the letter before the findings begin.
- Must The progress figures, because they show the pattern the GP needs (back improving, leg plateaued); the negative neurology, because it is what makes waiting safe; the eight weeks of ibuprofen, because it is the request; the safety-net advice, because the GP shares responsibility for it.
- Leave Geography, the partner, the running history, the high stool, the manual therapy, the run on 6 September, the reading about surgery online. The treatment detail is the physiotherapist’s business; the GP needs the outcome.
- May, cut Her anxiety about the leg. Relevant, but the letter is at 190 words and the next review will show whether it persists. A one-clause mention would have been acceptable.
- Genre Allied health professional to doctor: measurements given as numbers, findings in professional terms, the suggestion of a specialist opinion framed as a suggestion rather than an instruction.
04Pharmacy
Medication review request: hospital pharmacist to GP.
The case notes
Patient: Mrs Joan Whitaker, 79 years old
Admitted: 5 September 2026, Acute Medical Unit, St Anne's Hospital, after a fall at home
Discharge: 9 September 2026, home, with daughter staying for 1 week
Social history:
Lives alone in a bungalow. Daughter lives nearby, visits daily.
Manages her own medicines from the boxes; no compliance aid.
Three falls in the last 6 months; this is the first with injury.
Medical history:
Hypertension. Atrial fibrillation. Osteoarthritis of both knees.
Poor sleep for many years. Mild anxiety.
Chronic kidney disease stage 3 (eGFR 48).
No known drug allergies.
Medicines on admission (from boxes brought in by daughter):
Furosemide 80 mg every morning (dose increased in June for ankle swelling).
Bisoprolol 5 mg daily.
Apixaban 5 mg twice daily.
Amlodipine 10 mg daily.
Zopiclone 7.5 mg at night (prescribed since 2021).
Diazepam 2 mg, up to three times daily as required (started March 2026 for anxiety; taking twice daily most days).
Codeine 30 mg, up to four times daily (for knee pain).
Paracetamol 1 g four times daily.
Over the counter: diphenhydramine night-time tablets, most nights, bought herself.
Presenting complaint:
Fall getting up at night to pass urine; laceration to forehead, sutured. No fracture.
Lying and standing blood pressure: 138/80 lying, 104/62 standing (postural drop).
Sodium 131 mmol/L. eGFR 41. Confusion score normal.
Ankle swelling: minimal.
Hospital course:
Furosemide reduced to 40 mg daily; ankles unchanged; standing blood pressure 118/70 by day 3.
Diphenhydramine stopped: patient unaware it was a sedating antihistamine; agreed to stop.
Diazepam and zopiclone: continued during admission to avoid withdrawal; both flagged for gradual reduction.
Codeine: patient reports constipation and drowsiness; paracetamol alone tried on day 3, pain acceptable.
Falls team: assessed; home visit arranged; walking frame supplied.
Apixaban: dose appropriate for weight, age and renal function; continued.
Pharmacist recommendations for the GP:
Repeat renal function and sodium in 1 week.
Plan a gradual withdrawal of zopiclone, then diazepam, with the patient's agreement (leaflet given; patient willing).
Codeine stopped at discharge; paracetamol regular; review pain in 2 weeks.
Consider a bone health assessment: three falls, aged 79, no bone protection prescribed.
Suggest a weekly compliance aid; community pharmacy can supply.
Amlodipine: consider reducing if postural drop persists.
Writing task:
Using the information in the case notes, write a letter to Dr Ravi Menon, GP, Hillside Medical Practice, informing him of the medication changes made during Mrs Whitaker's admission and the review you recommend. Expand the relevant case notes into complete sentences. 180 to 200 words.
A model I wrote, at Grade B · 198 words · open after you have written yours
Dear Dr Menon,
Re: Mrs Joan Whitaker, aged 79
I am writing to inform you of the medication changes made during Mrs Whitaker's admission following a fall at home on 5 September, and to recommend a review of her sedative medicines.
On admission she had a postural drop, with a standing blood pressure of 104/62, a sodium of 131 mmol/L and an eGFR of 41. Her furosemide has therefore been reduced from 80 mg to 40 mg daily, after which her standing blood pressure recovered to 118/70 with no increase in ankle swelling. Over-the-counter diphenhydramine, taken most nights, has been stopped. Codeine has also been stopped because of drowsiness and constipation; her knee pain is acceptable on regular paracetamol.
She remains on zopiclone 7.5 mg and diazepam 2 mg twice daily, which were continued to avoid withdrawal. I would be grateful if you could plan a gradual reduction of both, to which she has agreed, and repeat her renal function and sodium within a week. Given three falls in six months, a bone health assessment may also be appropriate, and a weekly compliance aid could be supplied by her community pharmacy.
Yours sincerely,
Clinical Pharmacist
Acute Medical Unit
- Purpose Two things in one sentence: what has changed, and what is being asked. The reader can act on the letter from the first line.
- Must The postural drop and the blood results, because they explain the furosemide change; each stopped or changed medicine with its reason; the two sedatives still running, because they are the request; the renal check with its timing.
- Leave The bungalow, the daughter’s visits, the forehead laceration, the confusion score, the falls team and the walking frame, the apixaban check (confirmed appropriate, so nothing for the GP to do), the amlodipine possibility. A letter that lists everything reviewed reads as a record, not a request.
- May, kept The bone health assessment and the compliance aid, one sentence each at the end, because both are things only the GP can set in motion and both follow from the falls.
- Genre Pharmacist to doctor: drug names, doses and results given precisely; recommendations framed as recommendations. The patient’s agreement to the withdrawal is stated, because the GP will need it.
05Dentistry
Referral letter: dentist to oral surgeon.
The case notes
Patient: Mr Samuel Okoro, 45 years old
Practice: Marlow Dental Care
Date of this appointment: 9 September 2026 (emergency); regular attender, last check-up March 2026
Social history:
Warehouse manager. Married, two children.
Non-smoker. Alcohol: 10 units a week.
Anxious about dental treatment; copes well with local anaesthetic.
Medical history:
Deep vein thrombosis 2024; on warfarin, INR checked monthly at the anticoagulation clinic; last INR 2.6 on 2 September, target range 2 to 3.
Penicillin allergy (rash).
Otherwise well.
Dental history:
Good oral hygiene; brushes twice daily; no active caries at last check-up.
Lower right third molar (48): partially erupted, mesio-angular impaction, noted at check-ups since 2023.
Episodes of pericoronitis: October 2025 (settled with irrigation and metronidazole), May 2026 (irrigation; antibiotics not needed), and now.
Presenting complaint (today):
Pain and swelling around the lower right wisdom tooth for 4 days; difficulty opening the mouth; bad taste.
Examination: swollen, inflamed operculum over 48; pus on gentle pressure; limited opening (25 mm); tender right submandibular lymph node. Temperature 37.6.
Adjacent second molar (47): distal enamel caries, early, seen on the radiograph.
Radiograph (today): mesio-angular impaction of 48; roots close to the inferior dental canal; no periapical pathology.
Treatment today:
Irrigation under the operculum with chlorhexidine; local measures and analgesia advice.
Metronidazole 400 mg three times daily for 5 days prescribed (penicillin allergy; patient advised to avoid alcohol; warfarin interaction discussed, INR to be checked in 3 to 5 days, anticoagulation clinic informed by phone).
Review in 1 week.
Assessment and plan:
Third episode of pericoronitis in 12 months: removal of 48 indicated.
Not suitable for extraction in practice: root proximity to the inferior dental canal, warfarin, limited opening, patient anxiety.
Refer to oral surgery for assessment and removal, with anticoagulation management.
Caries in 47 to be restored in practice once the acute episode has settled.
Writing task:
Using the information in the case notes, write a letter to Mr David Sallis, Consultant Oral Surgeon, Oral Surgery Department, County Hospital, referring Mr Okoro for assessment and removal of the lower right third molar. Expand the relevant case notes into complete sentences. 180 to 200 words.
A model I wrote, at Grade B · 192 words · open after you have written yours
Dear Mr Sallis,
Re: Mr Samuel Okoro, aged 45
I am referring Mr Okoro for assessment and removal of his lower right third molar (48), which has now caused three episodes of pericoronitis in twelve months.
He attended today with four days of pain and swelling around the tooth, limited mouth opening of 25 mm, pus beneath the operculum and a tender submandibular node. Today's radiograph shows a mesio-angular impaction with roots close to the inferior dental canal and no periapical pathology. Previous episodes in October 2025 and May 2026 settled with local measures.
I have irrigated the area and prescribed metronidazole for five days, as he is allergic to penicillin. He takes warfarin following a deep vein thrombosis in 2024; his INR was 2.6 on 2 September, and the anticoagulation clinic has been informed of the interaction and will recheck his INR this week.
I do not consider the extraction suitable for practice, given the root position, his anticoagulation and his limited opening, and he is anxious about treatment. I would be grateful if you could assess him and manage his anticoagulation around the procedure.
Yours sincerely,
Dentist
Marlow Dental Care
- Purpose The referral and its reason in the first sentence: which tooth, what for, and why now.
- Must The acute findings and the radiograph, because the surgeon plans from them; the warfarin, INR, allergy and antibiotic, because they change the surgical plan and the timing; the three reasons the extraction is not for practice, because they justify the referral.
- Leave His job and family, the alcohol units, the oral hygiene, the caries in 47 (the dentist will restore it), the temperature, the one-week review, the analgesia advice.
- May, kept His anxiety, in four words, because it bears on sedation. Not the sentence about coping with local anaesthetic, which the surgeon will discover.
- Genre Dentist to consultant: tooth notation used once with the name in full, findings in clinical terms, the request specific about anticoagulation management rather than a general “please see”.
06The marker
Write the letter, then have it read.
The medicine case is loaded; the button on any case above loads that one instead. Set a timer for forty-five minutes, write to the reader in the task line, and have the letter read against the six criteria. The read is indicative, the same first read the writing checker gives, and nothing you write is stored.
0 words
An OET letter is 180 to 200 words.
–
Indicative grade, from the six scoresOET letter
·The six criteria
Fix this first
One fix, to show you the kind of thing
A first read against the six published criteria, built for one letter at a time. It marks the page, not the day: treat the grade as a rough position and the two lists as the work. The full marked letter, with every selection decision explained, is what a lesson is for.
→From knowing to doing
Four letters, marked, is a week of work. The fifth is the one that counts.
Do the four under the clock, read the models, and keep the two lists the marker gives you. In a lesson, I bring a fifth case you have not seen, you write it live, and we mark it together, criterion by criterion, with every selection decision explained: what you kept that the reader did not need, and what you cut that they did.
Lessons are £20 for fifty minutes, one to one with a native British tutor, with a written report after each. The Writing page has the method and the criteria; the OET hub covers the other three sub-tests.