Durable Medical Equipment Dispensing Note (Crutches, Brace, or Support)

Date and Time of Dispensing: [Date and time of device handoff]

Location/Site: [Clinic, unit, or department]

Patient Name and Identifiers: [Patient full name] — [Identifiers per policy]

Ordering/Treating Clinician: [Name, credentials, service]

Dispenser Name and Credentials: [Name, role, credentials]

Clinical Evaluation Date (if different from dispensing): [Same day / Date: ____] (If different, link this dispensing to the evaluation encounter.)

Indication & Order Verification

(Briefly link the device to the clinical context and order. Do not infer laterality, restrictions, or duration from the device; only document what is explicitly ordered or clarified.)

• Diagnosis/Problem: [Condition or problem linked to device]
• Laterality & Anatomical Region: [left / right / bilateral / midline / not applicable] — [Region]
• Intended Function: [immobilization / support / ambulation assistance / offloading]
• Weight-Bearing Status & Mobility Restrictions: [WBAT / PWB / TTWB / NWB / no restrictions / other: ____] — [Activity precautions if any]
• Anticipated Duration of Use: [Duration or "not specified"]
• Order Confirmation: [Order verified / clarification obtained / dispensing held pending clarification] — [Order location or reference]

Device Dispensed

(Create a separate item entry for each device dispensed.)

Item [#]

• Device Type & Description: [Type and description]
• Side/Laterality: [left / right / bilateral / not applicable]
• Size Selected & Measurement Basis: [Size] — [Measurements used and rationale]
• Quantity: [Number of units]
• Status: [new / reprocessed / loaner]
• Manufacturer & Model: [Manufacturer] — [Model]
• Serial or Lot #: [Value or "not available"]
• UDI: [Value or "not available"]
• Accessories Included: [List or "none"]
• Condition Verification: [Packaging intact or reprocessing label present; no visible damage or defects; moving parts functional; all fasteners secure]

Patient Assessment & Fit

• Pre-Fit Baseline Findings:
  • Skin Integrity: [Findings at anticipated contact areas]
  • Neurovascular Status: [Findings for affected extremity] (Include for compressive or immobilizing devices.)
  • Swelling: [Level and expected changes affecting fit]
  • Patient Factors Affecting Safe Use: [Balance, upper-extremity limitations, cognitive considerations, or "none identified"]
• Fitting Required: [yes / no — device requires no fitting]
• Measurements Used: [List measurements or "not applicable"]
• Size Selected & Rationale: [Size and rationale]
• Adjustments Performed: [Crutch height and handgrip position / brace hinge alignment and ROM settings / boot strap sequence and inflation level / other adjustments as applicable]
• Fit Assessment: [Alignment] — [Pressure points if any] — [Padding or modifications applied]
• Post-Fit Reassessment: [Skin and neurovascular findings] (Include for compressive or immobilizing devices.)
• Abnormal Findings & Escalation: [None / description with clinician notification and actions taken]

Training & Return Demonstration

(Include only the relevant subsection for the device type. Document observed performance rather than stating the patient "understands.")

Crutches

• Key Instruction: [Weight borne through hands; avoid axillary pressure]
• Gait Pattern Taught: [2-point / 3-point / 4-point / swing-to / swing-through] consistent with [weight-bearing status]
• Observed Return Demonstration: [Level ambulation] — [Turning] — [Obstacle negotiation] — [Stairs: performed / omitted due to ____]
• Caregiver Competency: [Name and relationship] — [Demonstrated skills] (Include if caregiver responsible for assistance.)

Braces and Orthopedic Supports

• Donning & Doffing Observed: [Independent / assisted] — [Technique adequate / needs reinforcement]
• Correct Placement Verified: [Anatomical landmarks aligned; orientation correct]
• Strap Tension & Closure Sequence: [Appropriate / adjusted]
• ROM/Lock Settings Verified Against Order: [Settings and values]
• Caregiver Competency: [Name and relationship] — [Demonstrated skills] (Include if caregiver responsible for device management.)

Education Provided

• Topics Covered: [Purpose and expected benefit; proper use and adjustment; weight-bearing and activity restrictions; daily skin monitoring with warning signs; fall prevention and home safety; signs requiring urgent attention; cleaning and maintenance; follow-up expectations]
• Written Instructions Provided: [yes / no] — [Language accommodations if used]
• Teach-Back Assessment: [Adequate / needs reinforcement] — [Objective description of performance]

Infection Control

[New device: packaging intact, no reprocessing required / Reprocessed or loaner device: cleaned and disinfected per facility policy]

Receipt & Follow-up

• Recipient: [Patient / designee: name and relationship]
• Return/Exchange Policy Explained: [yes / no]
• Signature Obtained: [yes / no — reason if not obtained]
• Follow-Up Plan: [Appointment scheduled / PRN return] — [Instruction to bring device if fit issues] — [Referrals if indicated]

Signature

Dispenser Signature: [Signature per policy] — [Date and time]

Addendum / Late Entry

(Use only if applicable. Label with author, date, time, and reason for late entry.)

[Addendum content]