Occupational Therapy · Referral letter · Intermediate

Occupational Therapy — Referral to Community OT after Stroke Discharge

An inpatient occupational therapist refers a 67-year-old man who has been discharged home after a stroke to the community OT for a home assessment and ADL rehabilitation programme. The letter must communicate the functional baseline and the outstanding assessment needs so the community OT can plan the first home visit.

Letter type

Referral

Write to

Community Occupational Therapist

Target length

180–200 words

The case notes

Patient: Mr Stanley Nguyen, 67 years old; right ischaemic stroke 3 weeks ago; mild left hemiparesis; discharged home today

Home: Lives alone in a first-floor flat (lift access); no family locally; receives home help twice weekly

Current ADL status: Independent in bed mobility and transfers with a rail; self-care (washing and dressing) — needs minimal assistance; manages short indoor walks (10 m) with a single-point stick; unable to cook independently (grip and balance)

Equipment discharged with: Grab rail (bathroom, fitted); perching stool (kitchen); single-point stick; long-handled shoe horn

Outstanding OT needs: Kitchen and cooking assessment; upper limb fine motor rehabilitation (writing, cutlery use); fatigue management education; review of ability to manage medications independently

Mood: Mildly low mood; finding the adjustment difficult; aware of community stroke group (referred by social worker)

Task: Write a referral letter to the community OT, Ms Aileen Burke, asking her to visit Mr Nguyen at home and carry out an ADL and equipment needs assessment.

Writing task

Write a referral letter to the community OT, Ms Aileen Burke, asking her to visit Mr Nguyen at home and carry out an ADL and equipment needs assessment.

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

  • That he lives alone in a first-floor flat with lift access and has home help twice weekly

    The community OT's visit planning depends on the home situation. Living alone tells them there is no carer present — all ADL assessments need to account for fully independent function, not assisted.

  • Current ADL baseline: independent in transfers, minimal assistance for washing and dressing, unable to cook independently

    This baseline allows the community OT to set goals for the home programme and identify the highest-priority safety concerns — cooking is the key unmet need.

  • The four outstanding OT needs: kitchen assessment, upper limb fine motor rehab, fatigue management, medication management

    This is the referral agenda. The community OT knows what to plan for at the first visit rather than starting from scratch.

Leave out

  • The stroke neurology and imaging detail

    'Right ischaemic stroke with mild left hemiparesis' is the context. The community OT does not need MRI findings to plan an ADL assessment.

  • The mood and community stroke group referral in detail

    The social worker has already referred him to the community stroke group. A brief mention — 'mild low mood; community stroke group referral arranged' — covers it.

Criterion in focus · Organisation & Layout

OT referral letters to community colleagues organise into: (1) who the patient is and why they are being referred, (2) current functional status, (3) the specific assessment or rehabilitation goals requested. Placing the equipment list before the functional status, or the outstanding needs before the baseline, creates a letter the community OT must re-read to extract the referral's purpose.

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 $12.

Questions about this case note

What does a community OT need from an inpatient OT referral?
Four things: the home situation (layout, alone or with carer), the current ADL function (what can they do, what are they struggling with), the equipment already in place, and the specific assessment or treatment goals being requested. Everything else is context. A referral that delivers all four lets the community OT write a session plan before the visit.
Should I include mood and psychological state in an OT referral letter?
Briefly, when it is relevant to ADL engagement. Low mood after a stroke is common and affects how much a patient will engage with an early rehabilitation programme. One sentence — 'mild low mood; finding the adjustment to disability difficult' — tells the community OT to frame the first visit supportively and not to overload with assessments.

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