Release of Information & Interprofessional Communication (Reflexology)

Document Header

Document Type: Release of Information + Interprofessional Summary

Date/Time Created: [Date and time with time zone]

Practitioner: [Practitioner name], [Credentials], [Certification/license number], [Clinic name], [Address], [Phone], [Secure fax], [Secure email]

Client: [Client full name], DOB: [Date of birth], Client ID: [ID if applicable]

Encounter Context: [Established / New] client; [In-clinic / Remote]; Date Range of Care Summarized: [Start date] to [End date / ongoing]

Confidentiality Notice: [Organization-specific confidentiality notice] (Include in header or footer on all pages along with client name and DOB.)

Release of Information Authorization

(This section must be complete and signed before any disclosure. If required elements are missing, do not transmit—resolve the omission first.)

Client Identification

Client Name: [Client full name]

Date of Birth: [DOB]

Contact Information: [Phone, email, mailing address] (Optional.)

Personal Representative: [Representative name], [Relationship], [Authority basis] (Include only if authorization signed by representative rather than client.)

Authorization Scope

(Specify minimum necessary content. Avoid blanket releases unless truly necessary.)

• ☐ Interprofessional summary letter (this document)
• ☐ Intake/history form
• ☐ Session attendance dates and durations
• ☐ Session notes (only if specifically authorized)
• ☐ Client-stated goals and client-reported responses
• ☐ Practitioner observations within scope
• ☐ Adverse events or precautions observed

Date Range Authorized: From [Start date] to [End date / all sessions through today]

Disclosing and Receiving Parties

Disclosing Party: [Practitioner or clinic name]

Recipient: [Clinician or clinic name], [Address], [Phone], [Secure fax or email]

(If multiple recipients, list each separately with complete contact information.)

Purpose of Disclosure

[Coordination/continuity of care / Client request / Referral communication / Shared care planning / Other: specify]

Expiration

Expiration: [Date or event] (Required element; e.g., "1 year from signature" or "completion of current treatment plan.")

Client Rights Statements

• You may revoke this authorization in writing at any time. Revocation does not affect disclosures already made.
• Your treatment or services [are not conditioned / are conditioned only as allowed by applicable law] on signing this authorization.
• Information disclosed to the recipient may be redisclosed and may no longer be protected by privacy regulations.

Signature

Client/Representative Signature: ____________________ Date: _________

Witness Signature: ____________________ Date: _________ (Include only if required by local policy.)

Copy of signed authorization provided to client: [Yes / No / Client declined]

(If client declines to authorize, document "Client declined ROI" and do not transmit. Consider offering a client-carried copy as an alternative.)

Transmission Record

(Complete when disclosure occurs.)

• Date/Time Sent: [Date and time with time zone]
• Method: [Secure fax / Secure email / Portal / Mail / Hand-delivered]
• Recipient Confirmation: [Fax confirmation / Read receipt / Verbal confirmation / Tracking number] (If obtained.)
• Attachments Sent: [List each attachment by title]
• Sent by: [Practitioner name / Staff delegate initials]

Interprofessional Communication Summary

To/From Header

To: [Clinician name and role], [Clinic or health system]

From: [Reflexology practitioner name], [Clinic]

Re: [Client name], DOB: [DOB]

Date: [Date]

Reason for Contact: [Brief statement of purpose]

Situation

[Current reason for communication and any concerns requiring medical input] (Two to four sentences. Use non-diagnostic language and clearly label urgency when applicable.)

Background

• Client-reported: [Relevant history, symptoms, or context provided by client]
• From referral note dated [date]: [Relevant details from documents in your possession] (Include only if applicable.)
• Observed: [Direct observations relevant to approach and safety] (Use non-diagnostic terms: skin integrity, tenderness, swelling, mobility, tolerance.)
• Precautions/Contraindications: [Factors affecting approach] (E.g., foot wounds, infection precautions, recent surgery, device locations.)

(If relevant medical history was not disclosed, state "Relevant medical history not provided by client.")

Assessment

(Scope-appropriate synthesis only—no medical diagnoses. Attribute any diagnoses to external clinicians if referenced.)

• Client-stated goals: [Goals and priority concerns in client's words when possible]
• Response patterns: [Client-reported responses] / [Observed responses] (Use terms like "tenderness," "reported discomfort," "client appeared relaxed," "skin intact.")
• Tolerance and safety: [Pressure tolerance, need for breaks, skin observations, positioning needs]

Care Delivered

Course Summary: [Start date] to [End date / ongoing]; [Number] sessions; [Frequency]; [Session duration in minutes]

• Approach: [Feet / Hands / Ears]; [Pressure style]; [Positioning accommodations]
• Modifications: [Areas avoided, technique adjustments, precautions applied] (Include only if applicable.)

Goals of Care:

• [Goal 1: functional or well-being focused]
• [Goal 2]
• [Additional goals or date-stamped revisions as applicable]

Client Response:

• Client-reported: [Outcomes using consistent anchors where possible] (Indicate timing: immediate vs. 24–72 hours.)
• Observed: [Relaxation cues, tolerance, skin integrity] (Indicate timing: during session vs. follow-up.)

Adverse Events: [Event description, severity, action taken, communication to recipient] (Include only if adverse events occurred; otherwise omit this field.)

Recommendation/Request

• Request: [Specific guidance needed from recipient] (E.g., confirm precautions, areas to avoid, pressure limits, infection precautions.)
• Proposed continuation plan: [Frequency], [Duration], [Functional goals] (Do not state disease outcomes.)
• Referral triggers: [Conditions prompting pause and urgent referral] (E.g., new skin breakdown, fever reported, sudden severe pain.)

Attachments

(Apply minimum necessary principle. Send full session notes only when specifically requested and authorized.)

• ☐ This interprofessional summary letter
• ☐ Session attendance list
• ☐ Other: [Attachment name]

Practitioner Attestation

Practitioner Signature: ____________________ Date: _________

Credentials: [Credentials]

Attestation: "Information above is accurate to the best of my knowledge and reflects client-reported information and practitioner observations within reflexology scope."

Staff Authentication: [Reviewer name], [Date] (Include only if authored by staff and reviewed by practitioner.)

Addendum

(Include only when corrections are needed after transmission. Do not overwrite transmitted summaries.)

• Addendum Date/Time: [Date and time with time zone]
• Author: [Name and role]
• Correction: [What is being corrected and why]
• Resent: [Yes / No]; Recipients: [Names/clinics if resent]