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Holistic Health Counselor

Documentation 205
Documenting Reason for Referral: Health Condition and Participation


  • Identify and classify various aspects of documenting reason for referral, including a patient’s background information, health condition, medications, past medical history, social history/participation, and prior functional status
  • Explain the 3 key elements of describing a patient's current health condition
  • Discuss the implications of direct access for documenting medical diagnoses
  • Describe the process of conducting an interview to obtain information pertaining to gathering history data
  • Appropriately document elements of reason for referral based on case scenarios

Joanne Brown, MS, OT, CHT

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