How to Write an Occupational Therapy Referral
A proper OT referral should include the diagnosis, assessment findings, medical investigation results, follow-up plans, other professionals involved, and the specific reason for referral, ideally after you have explained the diagnosis to the patient. 1
Essential Components of the Referral Letter
Your referral letter must contain the following information:
- Diagnosis: State the primary diagnosis clearly 1
- Duration and laterality of symptoms: Specify how long the condition has been present and which side(s) are affected 1
- Assessment findings: Include relevant clinical examination results 1
- Results from medical investigations: Document any imaging, lab work, or other diagnostic tests 1
- Follow-up plans: Indicate your intended monitoring schedule 1
- Other professionals involved: List any other specialists or therapists currently treating the patient 1
- Specific reason for referral: Clearly state whether this is for evaluation, treatment, or both 1
Common Indications for OT Referral
Refer to occupational therapy when patients have:
- Disability affecting daily activities: Personal care, domestic tasks, childcare, community or leisure activities 1
- Pain during activities of daily living: When pain impedes functioning and orthotics, assistive devices, or ergonomic adaptations may help 1
- Hand/wrist involvement: Requiring hand therapy, splinting, orthoses, or compression 1
- Need for care assessment: Determining care needs for people with disability 1
- Environmental access difficulties: Problems accessing home, education, work, or community environments 1
- Vocational needs: Support for employment, education, or voluntary roles 1
- Pain, fatigue, mental health, or cognitive difficulties: When these impede activity engagement 1
Timing and Patient Preparation
Explain the diagnosis to the patient before making the referral 1. This is critical because:
- Treatment is more likely successful when patients have some understanding and agreement with the diagnosis 1, 2
- Patients should agree to the referral 1, 2
- Patients need to understand that initial OT focuses on improving function, not just providing aids and adaptations 1, 2
What to Tell the Patient
When referring, explain to the patient:
- Reason for referral: The patient is seeing an OT for evaluation and treatment planning, not necessarily just to receive equipment 1
- What to expect: The evaluation will assess their functional abilities and may include recommendations for various interventions 1
- Decision-making process: There are multiple management alternatives, and decisions will be made collaboratively 1
Minimum Written Information Required
Document in writing:
- Duration of condition: How long the problem has been present 1
- Laterality: Which side(s) are affected 1
- Prior testing results: Include any hearing tests, tympanometry, or other relevant assessments 1
- Functional concerns: Suspected speech, language, or activity limitations 1
- Developmental status: Particularly relevant for pediatric referrals 1
Pitfalls to Avoid
- Insufficient information: Form letters containing structured information are superior to unstructured typed letters and ensure all necessary details are included 3
- Unclear expectations: Failing to clarify whether you're referring for evaluation versus immediate intervention creates confusion 1
- Omitting context: Not providing the patient's history of the condition and general medical status limits the OT's ability to tailor treatment 1
- Poor communication: Lack of clear documentation between referring clinician and OT leads to fragmented care 1