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Occupational Therapy Specialist
5-10 minutes

Outcome of Referral Letter Template

This referral outcome letter template is crafted for occupational therapists to effectively convey assessment results to the referring clinician. It features sections for patient demographics, medical history, functional assessment, and tailored recommendations. Occupational therapists can utilize this template to deliver a thorough analysis of a patient's capabilities and requirements, promoting seamless continuity of care. Optimized for integration with s10.ai, an AI medical scribe, this template enhances documentation efficiency and streamlines workflow. It is an excellent tool for occupational therapy professionals aiming to elevate their documentation practices.

1,475 uses
4.1/5.0
J
Jordan Ellis
Template Structure

Organized sections for comprehensive clinical documentation

[Date]
[Recipient's Name]
[Recipient's Department/Organization]
[Recipient's Company Name]
[Recipient's Contact Phone Number]
[Recipient's Contact Email Address]
Dear [Recipient's First Name],
Re:
[Patient's Full Name]
[Patient's Address]
[Patient's Date of Birth]
[Opening statement thanking the recipient for the referral and briefly mentioning the purpose of the assessment and when it was completed]
HEALTH PROFESSIONAL'S DETAILS:
[Health Professional 1's Full Name and Professional Qualifications]
[Health Professional 2's Full Name and Professional Qualifications]
RELEVANT MEDICAL INFORMATION:
[List of Patient's Relevant Medical Conditions]
CURRENT FUNCTIONAL STATUS:
MOBILITY:
[Indoor Mobility Status and Aids Used]
[Outdoor Mobility Status and Aids Used]
[Falls Risk/History]
PERSONAL ACTIVITIES OF DAILY LIVING:
[Showering Status and Aids Used]
[Drying Status and Aids Used]
[Dressing Status and Aids Used]
[Toileting Status and Aids Used]
DOMESTIC ACTIVITIES OF DAILY LIVING:
[Cooking Status and Aids Used]
[Housework and Gardening Status and Assistance Provided]
COMMUNITY ADL:
[Driving Status and Aids Recommended]
[Recreation/Leisure Activities and Level of Independence]
[Shopping Status and Level of Assistance Required]
[Appointment Management and Level of Assistance Required]
COGNITION:
[Cognitive Status and Observations During Visit]
[Power of Attorney Arrangements]
[Organizational Skills/Appointment Management Status and Aids Used]
[Medication Management Status and Aids Used]
[Money Handling/Bill Payment Status and Level of Assistance Required]
CURRENT SUPPORTS IN PLACE:
[Living Arrangements]
[Informal Supports Provided by Family Members]
[Formal Services Received]
HOME ENVIRONMENT:
ACCESS:
[Front Access Description and Recommendations]
[Back Access Description]
[Laundry Access Description]
BATHROOM:
[Shower Description and Aids in Place]
[Toilet Description and Aids in Place]
BEDROOM:
[Bed Size]
[Bed Transfer and Mobility Status]
SEATING:
[Dining Area Seating Description]
[Living Area Seating Description]
[Seating Transfer Status]
CLIENT'S GOALS:
[List of Client's Goals]
RECOMMENDATIONS:
[List of Recommendations]
ACTION COMPLETED:
[List of Actions Completed]
PLAN:
[Next Steps for Case Manager]
[Ongoing OT Input Status and Instructions for Re-referral]
[Closing statement thanking the recipient for the referral and inviting them to contact the OT if further assistance is needed]
Kind regards,
[OT 1's Full Name]
[OT 1's Designation]
[OT 1's Company Name]
[OT 1's Contact Phone Number]
[OT 1's Contact Fax Number]
(write in full sentences and do not use bullet points)
Thank you for referring [ClientFirstName].
I saw [ClientFirstName], aged [ClientAge] years, for review of their progress post sleeve gastrectomy on [SurgeryDate], at [number of weeks post surgery] weeks post-surgery.
Related issues:
[List relevant issues or concerns]
Background to condition:
[Background on why the patient gained weight]
Anthropometry:
Current weight: [CurrentWeight] kg, Height: [Height] cm, BMI: [BMI] kg/m²
[Percentage]% weight loss from baseline steady weight: [InitialWeight] kg on [InitialWeightDate]. Down by [kgs lost] kg over [time periond] months/weeks.
[Percentage]% weight loss from weight at the time of surgery: [SurgeryWeight] kg on [SurgeryDate]. Down by [kgs lost] kg over [time period] months/weeks.
Expected total weight loss at 12-18 months: [ExpectedWeightLoss] kg or [expected percentage] %
Current average weekly rate of weight loss: [WeeklyRateOfWeightLoss] kg/week
Previous weight loss attempts:
[Describe previous weight loss attempts]
Weight history:
Weight history over lifespan:
Heaviest adult weight: [HeaviestWeight] kg
How the patient feels about current body image and weight: [BodyImageFeelings]
Dietary assessment:
Regularity of eating pattern: [EatingPattern]
Portion sizes: [PortionSizeAssessment]
Comparison of diet against Australian dietary guidelines: [DietComparison]
Eating behaviours: [EatingBehaviours]
Social:
[Brief summary of drinking or smoking habits]
Living arrangements: [LivingArrangements]
Employment/study and hours of work: [EmploymentStatus]
Physical activity:
Current activity level: [CurrentPhysicalActivity]
Past activity level: [PastPhysicalActivity]
How the patient feels about physical activity: [PhysicalActivityFeelings]
Bowels:
Current bowel habits: [BowelHabits]
Bowel history: [BowelHistory]
Client perspective:
Why the patient wanted to have the surgery: [SurgeryReason]
Current feelings about the surgery and progress: [SurgeryFeelings]
Multivitamins:
[Compliance with multivitamin regimen]
Medications:
[List current medications and dosages]
Education:
[Education provided to patient]
Written materials provided:
[List any written materials given to the patient]
Plan:
[Summarize agreed plan]
Thank you for your referral. The next review appointment is on [NextReviewDate]. Feel free to contact me with any questions. I look forward to following up.
Kind regards,
[Clinician Name]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)
[OT 1's Contact Email Address]
[OT 2's Full Name]
[OT 2's Designation]
[OT 2's Company Name]
[OT 2's Contact Phone Number]
[OT 2's Contact Fax Number]
[OT 2's Contact Email Address]
Sample Clinical Note

Example of completed documentation using this template

October 15, 2023
Dr. Emily Johnson Neurology Department City Hospital (555) 123-4567 emily.johnson@cityhospital.org
Dear Emily,
Re: John Doe 123 Main Street, Springfield Date of Birth: January 1, 1950
Thank you for referring John Doe for an occupational therapy assessment, which was completed on October 10, 2023. The purpose of the assessment was to evaluate his current functional status and provide recommendations for ongoing support.
HEALTH PROFESSIONAL'S DETAILS: Dr. Sarah Thompson, OT, PhD Dr. Michael Lee, OT, MSc
RELEVANT MEDICAL INFORMATION: - Parkinson's Disease - Hypertension - Type 2 Diabetes
CURRENT FUNCTIONAL STATUS: MOBILITY: - Indoor: Uses a walker, independent - Outdoor: Uses a wheelchair, requires assistance - Falls Risk: High, history of recent falls
PERSONAL ACTIVITIES OF DAILY LIVING: - Showering: Requires assistance, uses grab bars - Drying: Independent - Dressing: Requires assistance with upper body - Toileting: Independent with raised toilet seat
DOMESTIC ACTIVITIES OF DAILY LIVING: - Cooking: Requires assistance, uses adaptive utensils - Housework and Gardening: Assistance provided by family
COMMUNITY ADL: - Driving: No longer drives, uses public transport with assistance - Recreation/Leisure: Enjoys reading, independent - Shopping: Requires assistance - Appointment Management: Requires assistance
COGNITION: - Cognitive Status: Mild cognitive impairment observed - Power of Attorney: Arranged - Organizational Skills: Requires assistance - Medication Management: Uses pill organizer, requires supervision - Money Handling: Requires assistance
CURRENT SUPPORTS IN PLACE: - Living Arrangements: Lives with spouse - Informal Supports: Provided by spouse and children - Formal Services: Home health aide visits twice a week
HOME ENVIRONMENT: ACCESS: - Front Access: Ramp installed, no further recommendations - Back Access: Steps, recommend installation of handrails - Laundry Access: Located in basement, requires assistance
BATHROOM: - Shower: Walk-in shower with grab bars - Toilet: Raised toilet seat with grab bars
BEDROOM: - Bed Size: Queen - Bed Transfer: Independent with bed rail
SEATING: - Dining Area: Standard chairs, no issues - Living Area: Recliner chair, independent transfer
CLIENT'S GOALS: - Maintain independence in personal care - Increase participation in community activities
RECOMMENDATIONS: - Install handrails at back entrance - Continue with home health aide services - Enroll in community exercise program
ACTION COMPLETED: - Home assessment completed - Recommendations discussed with family
PLAN: - Next Steps: Follow-up visit in 3 months - Ongoing OT Input: Continue as needed, re-referral if condition changes
Thank you again for the referral. Please feel free to contact me if further assistance is needed.
Kind regards,
Dr. Sarah Thompson Occupational Therapist Springfield OT Services (555) 987-6543 (555) 987-6544 sarah.thompson@springfieldot.org
Dr. Michael Lee Occupational Therapist Springfield OT Services (555) 987-6545 (555) 987-6546 michael.lee@springfieldot.org
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline patient assessments and enhance communication between healthcare professionals. By incorporating high-search healthcare and clinical keywords, this template ensures that all critical patient information is meticulously documented, from mobility and daily living activities to cognitive status and home environment. Clinicians can efficiently track patient progress post-surgery, evaluate dietary and physical activity levels, and manage medication and multivitamin compliance. The template also facilitates the documentation of patient goals and recommendations, ensuring a holistic approach to patient care. By adopting this template, healthcare providers can improve patient outcomes, optimize care coordination, and ensure thorough documentation for every patient interaction. Explore this template to enhance your clinical practice and ensure comprehensive patient care.
Frequently Asked Questions

Common questions about this template and its usage

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