Custom Foot Orthoses Evaluation/Delivery Note

(Select the Encounter Type and include only the sections applicable to that type. Do not output empty sections. Laterality (R/L) must be explicitly documented for all foot-specific findings and device specifications. For patients with diabetes, neuropathy, or prior ulceration, protective sensation assessment and neuropathy-specific break-in instructions are required; if not performed, document the reason and plan.)

Encounter Type: [Evaluation Only / Delivery Only / Combined Evaluation and Delivery]

Evaluation Date: [Date] (Include only if evaluation is performed in this encounter)

Delivery Date: [Date] (Include only if delivery is performed in this encounter)

Care Setting: [Care setting]

Clinician: [Name, credentials, role]

Referring Provider: [Name, credentials] (Include only if applicable)

Chief Concern / Indication

[Primary indication for custom foot orthoses] (In 1–3 sentences, start with why the patient is being seen for orthoses. Include the patient's stated concern when available, the primary diagnosis or condition, duration, aggravating/relieving factors, and functional impact.)

History

[Orthoses-relevant history] (Summarize pain characteristics [location with R/L, intensity, timing], functional limitations [walking/standing tolerance, activity restrictions], prior treatments and responses [PT, stretching, injections, prior orthoses, footwear modifications], current footwear profile and constraints, activity demands [occupation, sport, daily walking], and patient goals. Focus on details that inform orthotic design decisions.)

Medical/Risk History

• [Diabetes status and neuropathy risk] (State diabetes type/status. For high-risk patients, document protective sensation with method and results; if not assessed, state "Not assessed" with reason and plan.)
• [Peripheral vascular disease] (Include pulse history, prior vascular procedures if relevant.)
• [History of ulceration, wounds, or amputation] (Include locations with R/L and dates if known.)
• [Skin fragility concerns] (e.g., steroid use, edema, dermatitis, thin skin)
• [Material or adhesive allergies]
• [Relevant musculoskeletal or neurologic conditions affecting gait or foot mechanics]
• [Other risk factors or precautions impacting orthoses safety or design] (Include only if applicable)

Examination

(Document objective findings with explicit R/L laterality on all applicable items. Omit subsections not assessed unless clinically critical; for high-risk patients, skin and protective sensation must be documented or explicitly deferred with reason and plan.)

• Skin/Tissue: [R/L skin integrity], [callus pattern and locations], [wounds with locations and size], [edema], [footwear wear patterns]
• Neurovascular: [R/L pedal pulses], [capillary refill], [sensation screening method and results] (Required for high-risk patients; include monofilament results if performed)
• Alignment: [R/L arch height (pes planus/cavus)], [hindfoot alignment (varus/valgus)], [forefoot alignment], [hallux valgus], [toe deformities], [prominent metatarsal heads], [leg length discrepancy if relevant]
• ROM/Flexibility: [R/L ankle dorsiflexion], [first MTP ROM if relevant], [key strength findings influencing pronation/supination]
• Gait/Function: [Pronation timing], [heel strike pattern], [toe-off mechanics], [antalgic features], [single-leg stance stability]

Assessment

[Clinical summary] (In 2–4 sentences, link the chief concern to key objective findings and the orthotic rationale.)

1. [Problem 1: Working diagnosis] (Include key supporting findings and clinical risk level such as ulcer risk, fall risk, or deformity progression. Use "consistent with" or "suspected" for uncertain diagnoses. Order problems by clinical priority.)
2. [Problem 2: Working diagnosis] (Include only if applicable)
3. [Problem 3: Working diagnosis] (Include only if applicable)

Orthoses Plan

(Include for Evaluation and Combined encounters; omit for Delivery-only unless the plan is modified at delivery.)

Device Strategy: [Device type (functional / accommodative / hybrid)], [coverage (full-length / 3/4)], [intended rigidity], [footwear pairing requirements]

• Problem-Oriented Goals:
  • [Problem 1 goal] (Goal type: offloading / positioning / control / symptom relief; target anatomy; planned accommodations or modifications; brief rationale linking findings to features)
  • [Problem 2 goal] (Include only if applicable)
  • [Problem 3 goal] (Include only if applicable)

Footwear Requirements: [Removable inlay needed], [depth/volume requirements], [heel counter stability], [footwear restrictions or recommendations]

Impression/Scan Details

(Include for Evaluation and Combined encounters when capture is performed; omit for Delivery-only. If capture is deferred, document reason and interim plan instead of remaining fields.)

Capture Method: [Plaster cast / foam impression / 3D scan]

Positioning: [Non-weightbearing / semi-weightbearing / weightbearing]; [foot position intent (hindfoot alignment, arch contour goal)]

Landmarks Marked: [List landmarks] (Include only if applicable)

Scan/Cast ID: [File name or cast identifier]

Performed By: [Name, role]

Complications/Deviations: [Issues encountered] (State "None" if no issues)

Technical Specifications

(Summarize planned or delivered device specifications. If an external lab controls fabrication details, document what is known and include order number.)

• Device: [R / L / Bilateral], [Quantity]
• Lab/Manufacturer: [Name]; Order #: [Number] (Include if external fabrication)
• Shell: [Material], [rigidity]
• Posting: [Type], [amount/angles if measured]
• Top Cover: [Material], [length]
• Accommodations: [List with R/L and anatomic location] (e.g., "R 1st met head relief," "bilateral heel spur pocket")
• Edges/Trims: [Specifications if shoe volume is limited]

Delivery Verification

(Include for Delivery and Combined encounters; omit for Evaluation-only.)

Device Check: [Correct patient and laterality confirmed], [visual integrity (no cracks, delamination, sharp edges)], [R/L labeling present]

In-Shoe Fit: [Seating (flush contact / rocking noted)], [heel cup position], [arch contact], [trim adequacy]

Functional Trial: [Walking trial duration], [comfort level], [pressure points noted], [gait effect: improved / unchanged / worse]

Skin Check: [Post-trial inspection findings with R/L] (For high-risk patients, required: document erythema, blanching, or pressure marks and time to resolution.)

Outcome: [Accepted as-is / Modification needed / Remake required]

Adjustments

(Include for Delivery and Combined encounters.)

• [Adjustment performed] (What was modified; location with R/L; rationale; post-adjustment recheck result) (If no modifications needed, state "No modifications required at delivery" and omit additional bullets.)

Patient Education

• [Donning/doffing and placement instructions] (Include removal of original inlay if applicable)
• [Break-in schedule] (Gradual increase in wear time; stop if significant discomfort)
• [Skin monitoring instructions] (When to check, warning signs, when to contact clinic)
• [Neuropathy-specific precautions] (For high-risk patients: shortened initial wear periods and more frequent skin inspection)
• [Footwear guidance] (Supportive shoe requirements; avoid unsupportive footwear initially)
• [Care instructions] (Cleaning, drying, heat avoidance)
• [Return precautions] (Blisters, open sores, persistent pain, numbness changes, instability)

Written and verbal instructions provided; patient demonstrates understanding.

Follow-Up Plan

[Recommended follow-up interval] (Typically 2–4 weeks; sooner for high-risk patients.)

• [Reassessment targets] (Pain score, walking tolerance, skin/callus status, device wear pattern)
• [Triggers for earlier return or escalation] (Include if discussed)

Administrative Addendum

(Optional: Include only if required for billing or compliance. Keep separate from clinical documentation.)

• [Order/prescription details]
• [Proof-of-delivery elements: delivery date, address, signature method]
• [ABN or non-coverage notice if applicable]
• [Device codes and units]