Referral outcome letter

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