Referral Letter (Osteopathic Manipulative Medicine)

Date: [Date of letter]

From: [Sender name, credentials, clinic/practice, direct callback number]

To: [Recipient name/service, address if needed]

Patient: [Full name, DOB, MRN, contact number, interpreter need if applicable]

Referral Request

Type: [Consultation / Co-management / Procedure-focused request]

Urgency: [Routine / Semi-urgent / Urgent] [Brief rationale if urgent]

Clinical Question: [1–3 specific, answerable questions] (Avoid generic "evaluate and treat" requests; phrase as targeted clinical questions.)

Clinical Summary

• Chief problem: [Problem, duration, and clinical course] (Patient-reported)
• Working diagnosis: [Diagnosis or differential with level of certainty]
• Relevant history: [Pertinent PMH, surgical history, pregnancy/postpartum status, occupational/sport context as relevant]
• Medications: [Current medications] (Flag anticoagulants and chronic steroids prominently.)
• Allergies: [Allergen(s) with reaction types] (If unknown, state "Allergies: unknown—not confirmed at time of referral.")
• Prior workup: [Key imaging, labs, specialist evaluations with dates and high-yield findings]
• Prior therapies and response: [PT, prior OMT/chiropractic, injections, medications tried with response or intolerance]
• Pertinent exam findings: [ROM, focal tenderness, neurologic status, special tests] (Include only if performed.)
• Structural/Osteopathic findings: [Region-based TART-style findings if OSE performed] (If not performed, state "Structural exam not performed.")

Safety Considerations

[Relevant precautions for manual therapy] (Include anticoagulation status, osteoporosis/fracture history, malignancy or infection involving bone, inflammatory arthropathy or instability, recent surgery or hardware, neurologic red flags, positioning limitations. If not assessed, state "Not assessed." Do not leave blank.)

Request and Coordination

Treatment Focus: [Target body regions, symptom goals, and functional goals]

Technique Restrictions: [Any restrictions or patient preferences] (Only include if clinically justified; otherwise omit this field.)

Requested Deliverables: [What you need back—structural findings, treatment rationale, home program recommendations, follow-up interval, whether additional workup is recommended]

Care Coordination: [Who manages medications, imaging orders, PT referrals, work restrictions; preferred communication channel; whether written response is expected]

Signature: [Name, credentials, role, contact information]

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Consultation Summary

(Use this section for consultation response letters FROM the OMM provider. Omit any subsection not applicable.)

Reason for Referral: [Restate the clinical question as received]

Diagnoses: [Confirmed, new, or changed diagnoses including somatic dysfunction if identified]

Structural Findings: [Region-based TART-style OSE findings] (List only examined regions; if not performed, state "Structural exam not performed.")

OMT Performed: [Regions treated, techniques used, patient tolerance and immediate response, post-care instructions] (If no OMT performed, state "No OMT performed—evaluation only.")

Recommendations: [Medication suggestions, PT or home exercise program, imaging/labs if indicated, follow-up interval, task ownership delineation, return-to-work/activity guidance if applicable]

Signature: [Name, credentials, role, contact information]