OET Case Notes: OT Home Safety Referral (Beginner)
An occupational therapist writes to a patient's GP following a home safety assessment that identified moderate fall risk. This is a straightforward beginner referral: one key finding, one recommendation, and a clear handover. Ideal for practising the referral letter format before tackling complex multi-system cases.
Letter type
Referral
Write to
General Practitioner (GP)
Target length
180–200 words
The case notes
Patient: Mrs Dorothy Walsh, 78 years old
Living situation: Lives alone in a two-storey home; family nearby but not co-resident
Reason for assessment: Home safety assessment requested by GP following a recent near-fall on the stairs
Assessment findings: Moderate fall risk (Berg Balance Scale 42/56); staircase handrail absent on left side; bathroom has no grab rails; step thresholds throughout
Current mobility: Ambulant independently but reports dizziness on rising
Medical background: Type 2 diabetes, managed hypertension — no recent medication review
Modifications arranged: Stair grab rail installation arranged; fall-prevention programme recommended
OT plan: Review in 6 weeks once modifications in place; requesting GP medication review for dizziness on rising
Writing task
Write a referral letter to Mrs Walsh's GP, Dr James Brennan, outlining the home assessment findings, the risks identified, and requesting a review of her medications in relation to the reported dizziness.
What to include, what to cut
The hardest mark to win is selection. The same case notes contain decision-relevant facts and distractors. Here is what an examiner expects to see in a Grade B letter for this scenario, and what should be left out.
Include
The reason for assessment and the specific fall risk found
Purpose must be clear in the opening sentence; an examiner should understand the reason for the letter before the second line.
The dizziness on rising and the request for a medication review
This is the clinical handover — the key action being transferred to the GP. Omitting it makes the letter incomplete.
The home modifications already arranged
Telling the GP what has already been done frames the remaining gap clearly and prevents duplicate action.
Leave out
The full Berg Balance Scale scoring methodology
One score with context is sufficient. Explaining the tool wastes words and shifts focus from the clinical message.
Detailed management of the diabetes or hypertension
These are context only. The GP manages them — your job is to flag the postural-dizziness link, not re-manage the conditions.
Criterion in focus · Organisation & Layout
A referral letter has a clear three-part structure: reason for writing, findings, action requested. Markers notice when the action (medication review) appears before the findings, or when recommendations are buried mid-paragraph. Organise chronologically: assessment, what you found, what you have done, what you need from the reader.
Now write the letter — and find out what is blocking your Grade B
Write a 180–200 words referral letter from these notes, paste it into the free checker for an instant read, then submit it for a human grade against all six criteria. Dr Mariam's team returns line-by-line feedback, from $15.