OT Referral (Inpatient) 🏠
Guide for inpatient occupational therapy referral. Key information to provide, common indications (functional assessment, equipment, cognition, discharge planning), and referral scripts for NCHDs.
📋 Key Info to Have Ready
- Patient identifiers: name, DOB, MRN, ward and bed location
- Reason for referral, being specific: functional/ADL assessment, cognitive assessment, equipment provision, or discharge planning
- Baseline function: independent with ADLs (washing, dressing, cooking) or requiring assistance, and how that compares to now
- Home setup: house or apartment, stairs, downstairs toilet, who they live with, existing equipment or adaptations
- Current supports: home care package, family support, meals on wheels, day centre
- Cognition: any delirium, dementia, or new cognitive concerns this admission
- Falls history at home or during this admission
- Medical stability and whether the patient can participate in assessment
- Anticipated discharge destination and timeframe (home, home with supports, convalescence, rehab, or long-term care)
🔎 Common Reasons to Refer
- Functional/ADL assessment after acute illness, especially in older patients not returning to baseline
- Discharge planning: washing and dressing assessment, kitchen assessment, stairs and transfers in the context of home setup
- Equipment provision before discharge: commode, raised toilet seat, shower chair, grab rails, hospital bed
- Cognitive and functional assessment in delirium or suspected dementia
- Home environment concerns: self-neglect, hoarding, unsafe setup, or carer strain
- Assessment for home care package or increased supports on discharge
- Upper limb rehab and splinting (e.g. post-stroke, hand injuries), depending on local service
- Fatigue management and energy conservation in chronic disease or cancer
📞 Example Referral
- Hi, this is [Your Name], the intern from [Team Name]. I'd like to refer a [Age]-year-old patient on [Ward] for occupational therapy.
- They were admitted with [reason for admission] and are now medically [stable/improving]. We're referring for [e.g. functional assessment / discharge planning / equipment provision / cognitive assessment].
- At baseline they were [e.g. independent with ADLs, living alone in a two-storey house]. Currently they are [e.g. needing assistance with washing and dressing].
- They have [supports, e.g. a home care package twice daily / no formal supports], and cognition is [intact/impaired]. The plan is for discharge [home/home with supports/to rehab].
- Many hospitals use an electronic or paper referral form rather than a phone call. Include the same details there, and flag urgent discharges to the OT department directly.
📝 Tips
- Refer early: OT assessments (especially home visits and equipment orders) take time and are often the rate-limiting step for discharge
- Be specific about the question you want answered (e.g. 'is it safe for this patient to return home alone?') rather than just writing 'OT review'
- Collateral history from family or carers about baseline function is invaluable, so gather it before the OT assessment
- OT and physio often assess jointly; if both are needed, refer to both and say so in each referral
- Equipment for home (rails, commodes, hospital beds) can take days to arrange, so anticipate needs rather than waiting for the discharge date
- For complex discharges, raise the patient at the MDT meeting so OT, physio, social work, and the discharge coordinator are aligned
- If cognition is the concern, mention any formal testing already done (e.g. 4AT, MMSE, MoCA) and whether delirium has resolved
Educational reference only. Medical disclaimer