HLTCOM406C Practical Assessment: Healthcare Referrals and Reports

This practical assignment showcases the application of referral procedures in healthcare, including the creation of referral letters for three different clients presenting with acute pain, depression, and bruises respectively. Each referral letter includes the purpose of the letter, client details, treatment summaries, reasons for referral, and a consent section. The assignment also includes client consent forms, a contact directory listing various healthcare professionals, and a medico-legal report based on a client's history of injuries. The medico-legal report details the practitioner's qualifications, a summary of the client's condition, circumstances of injury, examination findings, past medical history, and treatment provided. The assessment demonstrates the ability to communicate effectively, formulate referral plans, and arrange referrals while adhering to privacy regulations.

Client 1
Referral letter
[Date]
To [Name of healthcare professionals or support services]
[Street Address]
[Suburb state post code]
Dear Sir
Purpose of letter: referring [client name] presenting with acute pain.
I am writing to refer [name of client] for assessment of acute and sharp pain in the right
shoulder.
Client’s details/Background
[Name of client] is moderately active, 60 year old with sharp pain in right shoulder for few
days since performing the gardening.
Treatment Summary
I have not been treating [name of client]
Reason for Referring
I have suspended the treatment procedure of [name of the client] as I feel this is out of my
scope of practice as a therapist.
Consent:
I have received full consent from [name of the client], to release his health information as per
Privacy Act 1988. I have enclosed his health details and a copy of his written consent.
Please do not hesitate to contact me should you require further information to assist you with
[client’s name]’s assessment.
Yours’ sincerely
[My name and contact details]

Client’s consent
[Client’s name]
[Street address]
Suburb state Post code- 4870
[Date]
[My name]
[Street address]
[Suburb state postcode]
Dear [My name]
As per the Privacy Act 1988, I consent to having my health information relating to my
treatment for my acute pain in right shoulder rendered by you on from [Dates] through
[dates] released.
This information is to be released for the purpose of referral to assist with my further health
assessment and will be provided to:
[Name of other health practitioners]
[Street address]
[Suburb state postcode]
Sincerely
[Client’s name and Signature]

Contact directory
Physiotherapist
Address...............................................................
Service provided.................................................
Fees associated...................................................
Hours of Operation..............................................
Naturopath
Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................
Aboriginal health worker
Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................
General Practitioner
Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................
Osteopath

Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................
Local Aboriginal Community Service
Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................

Client 2
Referral letter
[Date]
To:[Name of healthcare professionals or Support services]
[Street Address]
[Suburb state postcode]
Dear Sir
Purpose of Letter: referring Zara presenting with depression
I am writing to refer Zara for assessment of her signs of depression.
Client’s detail/Background
Zara is sedentary, 35 years old with pregnancy and signs of depression.
Treatment Summary
I have been treating Zara on a regular basis for four weeks mainly for her pregnancy related
issues.
Reasons for referring
I have suspended further treatment when I completed the assessment of presenting symptoms
of depression in the patient. She is in need of some mental asylum for her treatment.
Consent:
I have received full consent from Zara to release her health information as per Privacy Act
1988. I have enclosed her health details and a copy of her written consent.
Please do not hesitate to contact me should you require further information to assist you with
Zara’s assessment.
Yours sincerely
[My name and Contact details]

Client’s consent
Zara
[Street address]
[Suburb state Post code]
[Date]
[My name]
[Street address]
[Suburb state postcode]
Dear [My name]
As per the Privacy Act 1988, I consent to having my health information relating to my
treatment for my signs of depression during pregnancy rendered by you on from [Dates]
through [dates] released.
This information is to be released for the purpose of referral to assist with my further health
assessment and will be provided to:
[Name of other health practitioners]
[Street address]
[Suburb state postcode]
Sincerely
[Client’s name and Signature]

Contact Directory
General Practitioner
Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................
Naturopath
Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................
Australian Woman’s Muslim Association
Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................
Social worker
Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................
Massage therapist

Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................
Beyond Blue
Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................

Client 3
Referral letter
[Date]
To
[Street Address]
[Suburb state post code]
Dear Sir
Purpose of Letter: referring Julie presenting with Bruises
I am writing to refer Julie for assessment of large dark bruises and older bruises which is
yellowish in colour.
Client’s details/Background
Julie is active, 21 year old with a number of fractured bones in the ribs, nose, cheek bones,
right ulna and concussions to the head due to a violent de facto which she has been suffering
from the last four years.
Treatment summary
I have been treating Julie on a regular basis for more than three months, mainly for her
multiple fractured bones.
Reasons for referring
I have suspended further treatment until I have completed the assessment of Julie’s
presenting symptoms of large dark bruises as well as older yellowish bruises.
Consent:
I have received full consent from Julie to release her health information as per Privacy Act,
1988. I have enclosed her health details and a copy of her written consent.
Please do not hesitate to contact me should you require further information to assist you with
Julie’s assessment.
Yours sincerely
[My name and contact details]

Client’s consent
Julie
[Street address]
[Suburb state Post code]
[Date]
[My name]
[Street address]
[Suburb state postcode]
Dear [My name]
As per the Privacy Act 1988, I consent to having my health information relating to my
treatment bruises rendered by you on from [dates] through [dates] released.
This information is to be released for the purpose of referral to assist with my further health
assessment and will be provided to:
[Name of other health practitioners]
[Street address]
[Suburb state postcode]
Sincerely
[Client’s name and Signature]

Contact directory
General Practitioner
Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................
Naturopath
Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................
Professional counsellor
Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................
Acupuncturist
Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................
Domestic Violence Telephone Service

Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................
Women’s shelter
Address...................................................................
Service provided.....................................................
Fees associated........................................................
Hours of Operation.................................................