DME/Orthotics Order Note

Date/Time: [Date and time of documentation]

Setting: [clinic / ED / postop visit / inpatient discharge]

Patient: [Patient name, DOB, MRN]

Ordering Provider: [Provider name and credentials]

Order Summary

(List each ordered item on its own bullet.)

• [Device type and laterality]; [Functional intent: immobilize / stabilize / offload / assist gait / prevent contracture / correct alignment / restrict ROM]; [Diagnosis/condition addressed]; Start: [Date]; Duration: [Anticipated length of need]; Quantity: [Number if >1]; HCPCS: [Code if known] / (to be confirmed by supplier); [If replacement: reason for replacement]
• (Add additional bullets for each device ordered)

Clinical Indication & Medical Necessity

(Create a subsection for each condition driving a device order. If key criteria are not assessed, document "not assessed" or "unknown" rather than leaving blanks.)

[Condition/Diagnosis]

Diagnosis and relevant comorbidities: [Primary diagnosis]; [Comorbidities affecting device selection: neuropathy, skin fragility, cognitive impairment, balance disorder, deformity]

Clinical context: [Symptom onset, mechanism, and course]; [Prior surgery with date if relevant]; [Current phase of care]

Prior treatments and response: [Therapies attempted and response or intolerance]

Functional limitations without device: [Specific mobility-related ADL limitations]; [Falls risk or near falls]; [Ambulation distance and aids required]; [Work/school limitations if applicable]

Why device is needed now: [Justification in current stage of healing, rehab, or safety]

Expected benefit/goal: [Stabilize joint / restrict motion for healing / offload pressure area / prevent contracture / improve gait safety / improve independence]

(Add additional subsections for each diagnosis linked to an ordered device.)

Examination Findings

(Include only device-relevant objective findings.)

• Gait and balance: [Observations: antalgic, Trendelenburg, step-to pattern, assistance required]
• Range of motion: [Joint and degrees measured; end-feel or guarding if relevant]
• Strength: [Key muscle groups and grades]
• Stability/laxity testing: [Tests performed with findings: varus/valgus stress, anterior/posterior drawer, Lachman, talar tilt; side and grade] (For knee braces ordered for instability, if stability testing not documented, state: "Instability testing not performed—documentation incomplete for instability-brace justification.")
• Neurovascular and sensory status: [Light touch, pinprick, pulses, capillary refill]
• Swelling/effusion: [Location and severity]
• Skin integrity: [Wounds, edema, bony prominences, areas requiring pressure offloading]
• Relevant imaging: [Key findings with dates]
• Sizing measurements: [Limb circumferences with landmarks, shoe size, height, weight] (If deferred: "Sizing to be completed by orthotist/supplier at fitting.")

Device Selection & Specifications

Device type: [Brace / boot / splint / crutches / walker / CPM / other]; [Rigid / semi-rigid / soft]; [Articulated / non-articulated]; [Laterality]

Key features required: [ROM stops, varus-valgus adjustment, offloading regions, dorsiflexion assist, immobilization angle, padding needs, height/handgrip type, wheels/brakes, CPM ROM parameters]

Rationale for selection: [Why this device meets clinical goals and improves safety/function]

Why simpler alternatives are insufficient: [Limitations of simpler options for this case]

Custom vs OTS: [Custom-fitted / custom-fabricated / off-the-shelf] (If custom, state why OTS is not appropriate: [Atypical anatomy, high tissue injury risk, need for clinician-level adjustments, accommodation of healing fracture]; describe expected modifications.)

Use Instructions & Duration

• Start date: [Date]
• Wear/use schedule: [During ambulation / at night / continuous except hygiene / therapy sessions only / home use only]
• Weight-bearing status: [NWB / PWB / WBAT / as tolerated with device] (if applicable)
• Duration and rationale: [Timeframe with clinical rationale tied to healing timeline or functional goals] (If uncertain: [Bounded estimate with reassessment plan])
• Special parameters: [Immobilization angle, ROM settings, offloading zones, handle height, brake settings] (if applicable)
• CPM-specific: [Qualifying surgery type and date]; [CPM application date]; [Anticipated discharge date]; [Home-use timing and daily duration] (Include only if ordering CPM)

Follow-Up & Safety

• Fitting status: [Applied today by clinician / to be fitted by orthotist or supplier with location and timing]
• Patient education provided: [Donning/doffing, skin checks and pressure precautions, care/cleaning, weight-bearing and gait training, when to contact clinic]
• Demonstrated safe use: [Patient demonstrated correct use under supervision / requires further training]
• Follow-up plan: [Interval and location]; [Parameters to reassess: fit, skin, function, healing, ROM, pain, stability, imaging]
• Referrals: [PT/OT, orthotics/prosthetics, home health, supplier coordination] (if applicable)
• Supplier coordination: Documentation available to supplier upon request.

(Omit non-applicable sections rather than leaving empty fields. Do not fabricate findings. If required objective criteria for device justification are missing, flag as incomplete.)