Adaptive Recreation Equipment Assessment/Recommendation

Encounter Information

Patient: [Patient name], [MRN], [DOB]
Date/Time: [Encounter date and time]
Setting: [inpatient rehab / outpatient clinic / community / home / other]
Clinician: [Clinician name], [Credentials], [Role: CTRS / OT / PT / ATP / other]
Referring Provider: [Referring provider name or source of consult/order]
Note Type: [Assessment/Recommendation / Training Visit / Re-assessment / Discharge Equipment Summary]

Reason for Assessment

[Referral question and clinical decision to be made] [Device context: new device / replacement / upgrade] [Discharge context and intended use environments if applicable] (1–3 sentences. If referral question unclear, state that assessment was performed to determine safest option based on stated goals.)

Participants & Consent

[Attendees present: patient, caregiver(s), interpreter, vendor representative, therapy staff]

[Consent statement confirming patient agreed to device trial/training] (If no patient contact occurred, state "Chart review only" and note limitations.)

Recreation Profile & Goals

[Preferred activities, motivation, and why this equipment matters to the patient] (Brief narrative. Include a short direct quote if it supports funding justification or clarifies safety priorities. If goals documented elsewhere same-day, reference that note.)

• [Goal with measurable target: frequency, distance/time, or participation outcome]
• [Additional goals as applicable]

Relevant Medical/Functional Factors

(Problem-focused; include only factors directly affecting equipment fit, safety, or training.)

• [Diagnoses/impairments affecting device use: motor control, tone, coordination, sensation, cognition, vision]
• [Precautions/contraindications: weight-bearing, autonomic dysreflexia, seizure, cardiopulmonary, spine, skin]
• [Pain and endurance considerations]
• [Communication/cognition affecting safe operation]
• [Transfer and mobility baseline]
• [Current equipment and prior adaptive recreation experience]
• [Safety-critical items not assessed today] (State explicitly as "Not assessed today: ..." rather than leaving gaps.)

Context of Use

• [Primary environments: surfaces, terrain, slopes, water conditions, temperature]
• [Transportation plan: vehicle type, rack/lift, who assists]
• [Storage and maintenance capacity]
• [Supervision availability]
• [Community resources: adaptive sports programs, accessible trails]

(If equipment is for supervised facility use only, state that and omit community logistics.)

Assessment Methods & Findings

Methods:

• [Observation and fit measurements performed]
• [Standardized measures used and scores]
• [Safety checks performed prior to trial]

(If objective testing not feasible, document rationale and surrogate observations used.)

Findings:

• [Functional performance metrics: distance, time, assistance level, cues required]
• [Physiologic response if monitored: RPE, HR, BP, symptoms]
• [Safety events or near-misses and immediate response] (Only if occurred.)

Equipment Trials & Fitting

(Repeat for each device trialed. If no trial occurred, state reason and provide interim recommendations.)

[Device Name/Category]

• Device: [Category], [Manufacturer/Model], [Size], [Serial/Asset number] (Use "TBD" if not verified.)
• Configuration: [Seat/back supports], [Straps/harnesses], [Foot/leg positioning], [Controls], [Safety accessories: helmet, flotation, anti-tip, tether]
• Fit Assessment: [Pelvis/trunk/head alignment], [Limb clearance], [Pressure/skin tolerance], [Weight/size compatibility]
• Task Performance: [Mount/dismount method and assistance level: Independent / Supervision / Setup / Min Assist / Mod Assist / Max Assist], [Cues: None / Verbal / Visual / Tactile], [Propulsion/steering/braking], [Turns/terrain simulation], [Emergency stop]
• Safety Findings: [Stability/tipping risk], [Brake effectiveness], [Strap integrity], [Entrapment hazards], [Behavioral/judgment concerns]
• Patient Response: [Symptoms: pain, dizziness, fatigue], [Satisfaction], [Perceived difficulties]
• Decision: [Accepted / Rejected / Pending] (If rejected, document reason. If accepted, note preliminary specifications.)

Training & Competency

Training Provided:

• [Donning/doffing and device setup]
• [Transfers and mount/dismount techniques]
• [Operation skills: start/stop, steering, braking, emergency procedures]
• [Terrain/weather limits and environmental considerations]
• [Skin checks and symptom triggers]
• [Cleaning, maintenance, and pre-use safety checks]
• [Transport and storage procedures]
• [Teaching methods used: demonstration / guided practice / return demonstration / teach-back]
• [Educational materials provided]

Competency Determination:

• [Tasks patient can perform reliably and under which conditions]
• [Required assistance/supervision level for: setup, transfer, operation, emergency response]
• [Tasks not yet safe and remaining training needs]

(Document only competencies observed via return demonstration or teach-back. If competency cannot be validated, state that independent community use is not recommended.)

Caregiver Training: (Include if applicable.)

• [Caregiver tasks trained]
• [Caregiver demonstrated competency: Yes / No; details]
• [Remaining caregiver training needs]

Impression

[Summary of match between goals, abilities, and device demands]

• [Key safety risks identified and mitigations]
• [Readiness determination: supervised program use / independent home use / community use]
• [If not ready: required changes before advancement]

Recommendations

Recommended Equipment: [Device category], [Intended environments], [Critical specifications and accessories], [Size/configuration parameters] (If make/model not finalized, document recommended feature set and acceptable equivalents.)

Alternatives Considered: [Other options evaluated and rationale for non-selection]

Safety Requirements: [Supervision level], [Terrain/weather/water limits], [Required protective equipment]

Training Plan: [Additional sessions needed], [Target competencies], [Community program referrals]

Follow-up: [Routine check schedule], [Triggers for earlier follow-up: pain, skin breakdown, falls, device malfunction]

Discharge/Transition Plan

(Include only when equipment is for discharge or community use.)

• [Equipment available immediately vs pending delivery]
• [Initial use locations and graded exposure plan]
• [Follow-up appointments and timeframe]
• [Contact information for fit issues, skin concerns, device malfunction, or worsening symptoms]
• [Written instructions provided via: printed / portal / email]

Coordination of Care

(Include when action is required from other team members.)

• [Team members notified and communication method]
• [Items requiring follow-up by others: orders, referrals, equipment quotes, home trials]

Safety Events

(Include only if an event occurred during the encounter.)

• [Description of event]
• [Immediate response and patient outcome]
• [Device involved and configuration at time of event]
• [Incident report completed per policy / Not required]

Signature

[Clinician signature], [Credentials], [Date/Time]
[Co-signature] (If required by policy.)