Question

Case Study – Referral Report

Healthcare Professionals – Project

Case Study 1

You are required to review the needs of the following client, research relevant treating health practitioners or services in your local area, and develop a referral report of approximately 250 words.

Ensure that your referral includes the following information:

• Purpose of referral

• Client details/background

• Summary of treatment the client has received to date

• Reason for referring (including observed symptoms and limitations of expertise)

• Name and details of medical practitioner to be referred to (this must be an actual medical professional in your local area).

Use the additional health information in the client profiles to help develop your report. Use fictional information to complete any details you do not have access to.

You will need to demonstrate to your assessor that you can:

• Prepare referral reports that provide appropriate advice to the receiving health service about the case

• Identify health care systems and services with links to own practice

• Determine need for referral to other professional health services based on client needs and assessment indications

• Clearly communicate the need for referral

• Provide clear and accurate information about results of own testing and assessment and previous treatment

• Structure information logically, using language that the recipient will understand

• Work within scope of own practice

Case study 1 – Susan Smith

54 year old Susan Smith has been coming for treatment quite regularly for some time – approximately one and a half years with sessions sometimes increasing to 4 times per week. She presented with left shoulder pain due to sitting at her desk for long periods, due to the nature of her occupation.

Upon assessment she reports an inconsistent degree of improvement to the left shoulder. She reports a feeling of inflammation or minimal movement and on other occasions she reports a reduction in pain. She often takes anti-inflammatories to help with the pain and seeks additional health therapies such as reflexology and acupuncture.

Susan is a fit and relatively active 54 year old and has no previous health or medical conditions, though she is now receiving 4 sessions of therapy per week. Suggestions for self-management strategies and weaning off treatment have not been well received.

Question:

1:Clients name: Age:

2:Purpose of referral

3:Client details and background

4:Summary of treatment to date

5:Name of medical practitioner

6:Location and phone number of practitioner

7:Reason for referral (including observed symptoms and limitations of expertise)

Answer 1

• Client name: Susan Smith (female)          Age: 54 years

• Purpose of referral: patient with left shoulder pain due to sitting at her desk for long periods referred for physical therapy.

• Client details and background

Susan Smith a 54 year old woman is suffering from pain in left shoulder due to her occupation nature and sitting at her desk for longer periods. She is going through treatment across from one and half years with sessions quite regularly for some time recently increasing to 4 times per week. Upon assessment it is reported an inconsistent degree of improvement to the left shoulder. Report of a feeling of inflammation or minimal movement and on other occasions also reported a reduction in pain on often taking anti-inflammatories to help with the pain and seeks additional health therapies such as reflexology and acupuncture. Patient is a fit and relatively active and has no previous health or medical conditions, though she is now receiving 4 sessions of therapy per week. Suggestions for self-management strategies and weaning off treatment have not been well received.

• Summary of treatment to date

Following the patients history undergone several tentative differential diagnoses. It was possible that the patient’s symptoms were related to cardiac pathology due to a positive cardiac history. Further to that the patient had undergone a complete cardiac work up with stress testing with as suspected that the arm symptoms may reveal cardiac related. The results of this testing were negative. Potential mechanical sources of the patient’s symptoms that were considered included the shoulder complex with cervical spine. Following traditional physical therapy, the patient may show improvement in her resting pain level and change in her pain level during exacerbations. An ergonomic intervention should be performed following traditional physical therapy. At the conclusion of the full course of treatment (traditional physical therapy plus ergonomic intervention), Improvements in Rapid Upper Limb Assessment and Workstyle scores also were suggested.

Referred by :

Dr. XYZ

ABC city

Phone : 1234567890

• Reason for referral: Physical therapy plus ergonomic intervention.