Ankle-Foot Orthosis/Knee-Ankle-Foot Orthosis Delivery Note (AFO/KAFO)

Date: [Date of service]

Patient Name: [Full legal name]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Laterality: [RT / LT / Bilateral]

Location: [Clinic/facility name and room or department]

Clinician: [Name, credentials]

Note Type: [initial delivery / replacement / remake / adjustment follow-up]

Indication and Goals

Ordering Provider: [Name, credentials]

Primary Diagnosis: [ICD-10 or descriptive diagnosis]

Functional Indication: [Functional problem addressed by orthosis]

Clinical Indication Summary: [Brief linkage between condition, impairment, and need for AFO/KAFO] (Keep concise; reference prior evaluation in chart if available rather than duplicating details.)

Patient Goals:

• [Goal 1 in measurable/observable terms]
• [Goal 2 in measurable/observable terms] (Include if stated)
• [Goal 3 in measurable/observable terms] (Include if stated)

Key Patient Concern: "[Direct patient quote]" (Include if explicitly stated.)

Device Information

Device Type: [AFO / KAFO]

Design Category: [solid AFO / articulated AFO / posterior leaf spring / carbon floor-reaction / CROW / locked-knee KAFO / stance-control KAFO / other]

Laterality: [RT / LT / Bilateral] (Safety redundancy with header)

Manufacturer: [Manufacturer name]

Model: [Model name/number]

Size: [Size or custom-fabricated]

Serial Number: [Serial number] (If absent, state "no serial number on device")

Materials: [Primary materials and notable components]

Interface Components Delivered: [Liners, socks, padding with quantities/sizes]

Joint/Setting Details: [Plantarflexion stop angle, dorsiflexion assist, ROM limits, lock type/status, stance-control settings] (Include only parameters present on device.)

Pre-Fit Assessment

• Skin Integrity: [intact / wound present / fragile / unable to assess] (If unable to assess, document limitation and counseling provided.)
• Edema: [none / mild / moderate / significant] with [location/distribution]
• Protective Sensation: [intact / diminished / absent] (Note relevant conditions such as diabetic neuropathy.)
• Baseline Pain: [Location, intensity, quality] (Include if relevant.)
• Weight-Bearing Status: [WBAT / PWB / NWB / other restrictions]

(If fitting deferred due to contraindications, document: [Reason for deferral], [Plan and follow-up arrangements].)

Fitting and Alignment

Donning Performed By: [clinician / patient / caregiver] with [assistance level]

Static Fit Assessment:

• Heel Seating and Footplate: [Heel seating status]; [Footplate length and coverage adequacy]
• Ankle Angle In-Brace: [Neutral / plantarflexion / dorsiflexion] with [clinical rationale]
• Trimline Clearance: [Malleoli, navicular, base of 5th metatarsal, tibial crest clearance findings]
• Strap Sequence and Tension: [Sequence and tension guidance]

KAFO-Specific Alignment: [Knee joint center alignment, thigh band placement, calf band placement, lock engagement/disengagement reliability] (Include for KAFO only.)

Modifications Performed:

• [Action + location + purpose] (e.g., "Heat relief created at medial malleolus to reduce focal pressure")
• [Additional modifications as needed]

(If none required, state: "No modifications required at delivery.")

Gait Assessment

(Include only if device is intended for ambulation and gait was assessed. If not assessed, state: "Gait assessment not performed due to [reason]; standing fit and safety checks completed.")

• Test Conditions: [Surfaces: parallel bars / level floor / ramp / stairs]; [Footwear worn]; [Assistive device]; [Assistance level]
• Comparison Without Orthosis: [performed / not performed] with [baseline gait features if performed]
• Observed Gait with Orthosis: [Toe clearance in swing, initial contact pattern, stance-phase knee stability, tibial progression control, patient-reported stability and comfort]
• Safety Events: [none observed / near loss of balance / pain onset / mechanical issues] with [description and response if applicable]
• Outcome Measures: [Timed walk, TUG, or other with results] (Include only if performed.)

Post-Trial Skin Check

• Inspection Performed: [Yes / No] (If socks not removed, document limitation and reason.)
• Findings by Location: [Malleoli, navicular, base of 5th metatarsal, tibial crest, fibular head, calf band edges, popliteal area] – [intact / mild transient erythema / persistent erythema / blistering / abrasion / numbness] (Include KAFO-specific locations as applicable.)
• Actions for Abnormal Findings: [Adjustment/modification, padding, education, recheck plan]
• Risk Factors: [neuropathy / diabetes / vascular disease / fragile skin / none identified] (Document enhanced monitoring instructions and caregiver training if applicable.)

Footwear

• Footwear Used: [Type, brand/model if known]
• Adequacy: [Depth, width, heel counter, closure assessment]
• Orthosis-Shoe Interface: [Fits fully without pressure/pistoning / issues encountered]
• Guidance Provided: [Acceptable shoe styles, shoes to avoid, sock requirements]
• Incompatibility and Plan: [Problem identified and resolution plan] (Include if applicable.)

Education and Training

Topics Covered:

• Device purpose and expected benefit: [Discussed]
• Donning/doffing and strap sequence: [Taught and practiced]
• Correct positioning: [Reviewed]
• Wear schedule: [Break-in plan reviewed]
• Skin inspection: [Normal vs abnormal findings, redness threshold explained]
• Sock and shoe requirements: [Reviewed]
• Cleaning and maintenance: [Instructions provided]
• Safety warnings: [No self-modification, heat avoidance, inspect for wear, when to contact orthotics]

Competency Demonstration: [Patient demonstrated independent donning/doffing / requires assistance from caregiver]

Caregiver Training: [Caregiver present and trained with return demonstration / not applicable]

Verification: [Competency statement documenting teach-back] (e.g., "Patient correctly repeated wear schedule and skin-check instructions via teach-back.")

Incomplete Education: [Topics covered today], [Remaining topics], [Plan for completion] (Include if education was not completed.)

Wear Progression

• Break-In Schedule: Start [initial duration] per day; increase by [increment, typically 30-60 minutes] daily; goal [target hours/day or activity-specific wear]
• Skin-Check Threshold: Stop use and contact orthotics if redness persists beyond [clinic threshold in minutes], or if pain, numbness, or skin breakdown occurs
• High-Risk Modifications: [Slower progression, daily skin checks, caregiver assistance requirements] (Include for patients with neuropathy, diabetes, vascular disease, or fragile skin.)

Follow-Up Plan

• Follow-Up: [Scheduled date or recommended timeframe]
• Anticipated Adjustments: [Strap re-tensioning, joint setting adjustments, interface padding, other]
• Triggers for Earlier Follow-Up: [Skin issues, pain, mechanical problems, instability, device non-use]
• Referrals/Coordination: [PT for gait training, communication to ordering provider, other]

(Do not document benefit, skin integrity, or understanding without direct observation or verified teach-back from this encounter. If a clinically expected element could not be performed, include a one-line reason rather than leaving blank.)