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 2 – John Benji

71 year old John Benji has presented for treatment of left knee pain due to an injury sustained whilst working as a labourer in his late 30s. John has experienced trouble walking up stairs and standing for long periods of time. He uses a walking stick to help with the balance and keep weight off the left leg. He reports a flare up of pain generally in the early mornings. The pain in the knee displays symptoms of a combination of chronic bursitis and osteoarthritis.

He has had several cortisone injections and anti-inflammatory medications in the past to ease and reduce the inflammation, however this has not been successful on the last few occasions. As well as seeking massage therapy, John is exploring alternative therapies such as hydrotherapy and reflexology to assist with pain management.

Question:

CLIENT REFERRAL REPORT – CASE STUDY 1

Clients name:

Age:

Purpose of referral

Client details and background

Summary of treatment to date

Name of medical practitioner

Location and phone number of practitioner

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

Answer 1

CASE STUDY 1:

Dear Sir,

This case is for your kind refferal and evaluation.

Name of the patient: Mrs. Elamma Joseph

Age: 72 years

Purpose for referral : For cardiac evaluation and necessary management.

Clients background: Mrs. Elamma is hypertensive with B.P of 190/105 mmHg upon admission.She have suspected cardiac hypertropic changes in ECG. Her sodium is low i.e 125 meq/L. She is complaining of chest pain and heart burn with numbness of right jaw. He has a past history of hyponatremia. She is receiving Tab. Amlodipine 10mg OD and Tab Alprax 0.5mg for sleeplessness.

Summary of treatment to date: She has received Inj. Pantoprazole 40mg IV, Tab Nifidepine 20mg SL stat, Inj. 3% of sodium chloride IV over six hours was started.

Reason for referral : Non availability of cardiac subspeciality within the hospital and non availability of cardiologist during night hours.

Name of the practitioner: Dr.Mohammad Hassan Hamdona, KIng AbdulAziz Specialist Hospital, KSA

04745023689