13.3 Referral Sources, Records Review & Medication Effects
Key Takeaways
- The blueprint names referrals, client records, developmental history, IEP plans, and theoretical approach or frame of reference as the resources an OTR uses to acquire information about a client's current condition.
- Medication side effects and interactions are an explicitly listed knowledge statement under Domain 1 Task 2, alongside roles, habits, routines, environmental context, family supports, and mental health.
- Occupational therapists do not prescribe or adjust medications; they observe functional effects, time sessions around peak and trough effects, and report suspected adverse effects to the prescriber.
- Beta blockers blunt the heart-rate response to exercise, so exertion must be graded with a rating of perceived exertion scale rather than a target heart rate.
- Anticholinergic burden, benzodiazepines, and polypharmacy of five or more medications are leading modifiable contributors to falls, confusion, and functional decline in older adults.
Referral Sources, Records Review & Medication Effects
Domain 1, Task 2 requires knowledge of resources and considerations for acquiring information about the client's current condition and occupational performance — the blueprint lists referrals, client records, developmental history, Individualized Education Program (IEP) plans, and theoretical approach or frame of reference. The same task lists medication side effects and interactions among the internal and external factors influencing engagement in occupation. Both are tested as pre-evaluation reasoning: what you must know before you ever put hands on the client.
1. Referral Pathways and Practice Authority
| Setting | Typical Entry Point | Key Constraint |
|---|---|---|
| Acute care / inpatient rehab | Physician or advanced practice provider order | Order specifies evaluation and treat; precautions and weight-bearing status must be confirmed in the record before mobilizing |
| Skilled nursing | Physician certification of a plan of care | Recertification intervals govern continued coverage |
| Outpatient | Varies by state — some jurisdictions permit direct access for evaluation, others require a referral for treatment or for payment | Always defer to the state practice act; a payer may also require a physician order even where the state does not |
| Home health | Physician-certified plan of care plus homebound status | OASIS assessment drives the episode |
| School (IDEA Part B) | Referral through the school team; parental consent for evaluation | OT is a related service and must be educationally relevant |
| Early intervention (IDEA Part C) | Referral to the state EI system; IFSP team | OT can be a primary service; delivered in natural environments |
Exam trap: "Can the OTR evaluate this client without a physician order?" The keyed answer is essentially always "It depends on the state practice act and the payer" — never a flat yes or no.
2. A Systematic Chart Review Sequence
Reviewing the record in a fixed order prevents the most dangerous omission — starting a transfer without knowing the weight-bearing status.
- Reason for referral and admitting diagnosis. What question is the team asking you to answer?
- Precautions and restrictions. Weight bearing, surgical precautions (posterior hip, sternal, spinal), activity restrictions, seizure precautions, aspiration precautions, fall risk level.
- Isolation status and code status. What personal protective equipment is required before entering? Is there an advance directive or do-not-resuscitate order?
- Current medical stability. Most recent vital signs, oxygen requirement, lines and drains, laboratory values, telemetry findings.
- Imaging and operative reports. Fracture pattern, fixation hardware, graft placement, surgeon's mobilization protocol.
- Medications. New starts, sedatives, anticoagulants, cardiac agents, timing of doses relative to your session.
- Prior level of function (PLOF). The single most predictive data point for discharge planning — who was this person two weeks ago?
- Social and discharge context. Home layout, stairs, caregiver availability, insurance, transportation.
- Other disciplines' notes. Nursing, physical therapy, speech-language pathology, case management — to avoid duplication and to inherit precautions such as diet texture.
For pediatric clients, add the developmental history (pregnancy, gestational age at birth, birth weight, NICU course, milestone attainment, feeding history) and the current IEP or IFSP, including present levels of performance, existing goals, accommodations, and the service delivery model.
3. The Frame of Reference Shapes What You Look For
The blueprint lists theoretical approach and frame of reference as an information-gathering resource, which is easy to overlook. Your chosen lens determines the data set:
| Frame of Reference | What You Go Looking For |
|---|---|
| Biomechanical | Range of motion, strength, endurance, tissue healing timeline, edema |
| Motor learning / task-oriented | Practice conditions, feedback schedule, environmental variability, task success rate |
| Rehabilitative / compensatory | Existing equipment, home layout, caregiver capacity, residual abilities |
| Allen Cognitive Disabilities | Level of cueing that produces success, error recognition, safety judgment |
| Ayres Sensory Integration | Sensory history, response to modalities, praxis, adaptive responses |
| Cognitive-behavioral | Automatic thoughts, avoidance patterns, activity-mood relationships |
| MOHO | Volition, habituation, roles, environmental affordances |
Selecting a frame before choosing assessments is what makes an evaluation efficient rather than a shotgun battery.
4. Medication Effects the Occupational Therapist Must Recognize
| Class / Example | Functional Effects Relevant to OT | Session Implication |
|---|---|---|
| Beta blockers (metoprolol, atenolol) | Blunted heart-rate response; fatigue; may mask hypoglycemia symptoms | Grade intensity with a rating of perceived exertion scale, not a target heart rate |
| Diuretics (furosemide) | Urinary urgency and frequency; orthostatic hypotension; electrolyte disturbance | Schedule around dosing; plan toileting access; slow position changes |
| Antihypertensives / nitrates | Orthostatic hypotension, dizziness | Sit before standing, check symptoms with position change |
| Opioids | Sedation, slowed processing, constipation, respiratory depression; blunted pain feedback | Do not push range of motion during peak analgesia — pain is a protective signal |
| Benzodiazepines | Sedation, ataxia, impaired new learning, falls | Avoid teaching new procedures at peak effect; high fall risk |
| Anticholinergics (oxybutynin, diphenhydramine, some antipsychotics) | Confusion, dry mouth, blurred near vision, urinary retention, constipation | Cumulative "anticholinergic burden" is a leading reversible cause of confusion in older adults |
| Typical antipsychotics (haloperidol) | Extrapyramidal symptoms: akathisia, drug-induced parkinsonism, acute dystonia, tardive dyskinesia | Report new involuntary movements or motor restlessness promptly; these are drug effects, not new neurological disease |
| Lithium | Narrow therapeutic index; toxicity produces coarse tremor, ataxia, confusion, vomiting | Dehydration and nonsteroidal anti-inflammatory drugs raise levels — report new tremor or ataxia urgently |
| Levodopa / carbidopa | ON-OFF fluctuation; peak-dose dyskinesia; orthostatic hypotension | Schedule high-demand ADLs during ON periods |
| Corticosteroids (prednisone) | Proximal myopathy, skin fragility, osteoporosis, hyperglycemia, mood lability | Avoid heavy resistive loading of proximal muscles; protect fragile skin during transfers |
| Anticoagulants (warfarin, direct oral anticoagulants) | Easy bruising and bleeding | Avoid aggressive passive range of motion and deep soft tissue work; check current coagulation status |
| Statins | Myalgia, proximal weakness | New unexplained muscle pain warrants a report to the prescriber |
| Fluoroquinolone antibiotics | Tendinopathy and tendon rupture risk | Defer heavy resistive tendon loading; report new tendon pain |
| Chemotherapy agents (taxanes, platinum agents, vincristine) | Chemotherapy-induced peripheral neuropathy, fatigue, thrombocytopenia | Sensory precautions, energy conservation, activity modified to platelet count |
Two Concepts That Generate Items
- Polypharmacy: commonly defined as five or more concurrent medications. It independently predicts falls, delirium, and functional decline. Recognizing it and reporting it is within OT scope.
- The prescribing cascade: a side effect is mistaken for a new condition and treated with another drug — for example, drug-induced parkinsonism from an antipsychotic treated with a dopamine agonist. Reporting an accurate functional observation is what breaks the cascade.
- The Beers Criteria published by the American Geriatrics Society catalogue medications that are potentially inappropriate in older adults; anticholinergics, benzodiazepines, and sedative-hypnotics feature prominently.
5. Scope Boundaries — Where the Exam Draws the Line
Occupational therapists do not prescribe, adjust doses, discontinue, or advise a client to stop a medication. What they do:
- Observe and objectively document functional effects ("Client required two rest breaks and demonstrated a resting tremor of the right hand during grooming, new since Tuesday").
- Time sessions around peak effect and trough effect.
- Screen for and report suspected adverse effects to the prescriber or nurse.
- Train medication management as an occupation — pill organizers, alarms, blister packs, low-vision labeling, and cognitive strategies for adherence. Under OTPF-4 this sits within Health Management, a standalone occupation category, not within IADLs.
- Educate on the functional consequences of a drug (for example, why a diuretic requires a bedside commode at night).
An occupational therapist is planning a graded activity tolerance program for a client in cardiac rehabilitation who takes metoprolol, a beta blocker. Which approach to monitoring and grading exercise intensity is MOST appropriate?
During a morning ADL session in a skilled nursing facility, an occupational therapist notices that a resident recently started on haloperidol now shows a new pill-rolling tremor, cogwheel rigidity at the elbow, and constant motor restlessness with an inability to sit still. What is the MOST appropriate action?
An occupational therapist receives an order to evaluate and treat a client on postoperative day one following an open reduction and internal fixation of the left femur. Which information must the therapist confirm in the medical record BEFORE beginning the session?