Allied Health Referrals: How to Document, Track, and Close the Follow-Up Loop

A Referral Is Not Complete When It Is Sent

A note that says "referred to physio" records an intention, not an outcome. Safe care coordination requires the team to track whether the referral was accepted, when the person was assessed, what was recommended, and whether those recommendations were implemented and reviewed.

This applies to physiotherapy, occupational therapy, speech pathology, dietetics, podiatry, psychology, behaviour support, and other allied health services.

The Five Stages of Referral Documentation

1. Reason for referral

Describe the observation, change, goal, or risk prompting the referral. Link it to the person's priorities and current care plan rather than using a generic request.

2. Consent and participation

Record how the person was involved, information provided, preferences such as appointment format or timing, and any representative involvement required.

3. Referral details

Document the discipline or service, date sent, urgency, relevant information shared, and the team member responsible for tracking the response. Follow privacy and consent requirements.

4. Assessment and recommendations

Summarise recommendations accurately, identify the source, and attach or store the formal report in the approved location. Do not translate professional advice into a different instruction without authorisation.

5. Implementation and review

Record care plan updates, equipment, staff education, trial periods, outcomes, and the next review date. If a recommendation cannot be implemented, document the barrier and escalation.

Example Referral Note

"During morning support, David needed two-person assistance to rise from his usual chair; baseline is one-person standby assistance. He reported no pain but said his legs felt weaker. RN assessed and discussed physiotherapy review with David, who agreed and requested a morning appointment. Referral sent to contracted physiotherapist at 11:10 AM with current mobility plan and relevant observations. Team leader assigned to confirm appointment by tomorrow. Until review, staff to follow RN's interim transfer instructions and record any further change."

Example Follow-Up Note

"Physiotherapist assessed David at 10:00 AM and recommended a higher chair, twice-daily supervised exercises, and review in seven days. David practised the exercises and said the pace was manageable. RN updated mobility care plan at 11:30 AM. Equipment request submitted; temporary approved chair placed in room. Afternoon staff briefed at handover. Review booked for 30 June, with team leader responsible for confirming equipment delivery."

Common Referral Gaps

• No clear reason or urgency recorded.
• No evidence that the person consented or participated.
• Referral sent but no owner assigned to follow it up.
• Recommendations filed without updating daily support instructions.
• Equipment or training delays not escalated.
• No outcome documented after the intervention.

Use a Simple Referral Register

Track the referral date, service, reason, priority, consent, appointment status, recommendations received, implementation owner, and review date. Review open items during clinical or care coordination meetings so delayed actions remain visible.

When recommendations change the person's support, ensure progress notes and the care plan stay aligned. See how to align care plans and progress notes for practical examples.

This article was written by AccuNote's Integrated Care Team to help providers maintain clear accountability across referral, assessment, implementation, and review.