Gait/Assistive Device Assessment Note

Date of Service: [Date]

Start/Stop Time: [Start time – Stop time] (Include only if captured)

Setting: [inpatient / outpatient / home health / SNF]

Clinician: [Name, credentials, role]

Encounter Type: [evaluation / re-evaluation / treatment visit / consult]

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

Caregiver Present: [Name, relationship] (Include only if applicable)

Reason for Assessment

[Primary reason for assessment and clinical decision being addressed] (1–3 sentences linking purpose of visit to device selection, gait training, or mobility safety assessment. Include contextual constraints only if they materially affect recommendations.)

Precautions and Safety Setup

• Weight-Bearing Status: [Status] per [order / protocol / patient report / unknown] (If unknown, state how this affected the session.)
• [Surgical or fracture precautions with laterality and timeframes] (Include only if applicable)
• Fall Risk: [low / moderate / high] – requires [supervision / CGA / min assist / ...]
• [Cognitive or behavioral safety considerations] (Include only if present)
• [Lines, tubes, or equipment affecting mobility] (Include only in applicable settings)
• [Cardiopulmonary considerations] (Include only if relevant to device selection or session safety)

Subjective

Chief Concern: [Patient-stated concern in their words] (Include when clinically useful)

• Current device use and problems: [Devices used and issues encountered]
• Goals and priorities: [Desired independence level, device preferences, confidence or fear of falling]
• Falls history: [Frequency, context, injuries, device involvement] (Note "not obtained" if relevant and unavailable)
• Home/community context: [Surfaces, stairs, narrow spaces, carrying tasks, community ambulation demands]
• Symptoms impacting gait: [Dizziness, neuropathy, vision, pain, fatigue] (Include severity and pattern if reported)

Objective

Baseline Mobility

• Transfers: [Task] – [Independent / Supervision / CGA / Min / Mod / Max / Dependent] – [Cueing type and frequency] – [Quality and safety observations]
• Static Standing Balance: [Condition] – [Assistance level] – [Cueing] – [Observations or loss-of-balance events]
• Dynamic Standing Balance: [Task] – [Assistance level] – [Cueing] – [Observations]

Standardized Measures

(Include only if performed; omit subsection entirely if none performed unless absence affects clinical reasoning)

• [Test name] – [Conditions: footwear, device, assistance] – [Score or time] – [Brief interpretation]

Gait Observation

[Distance and environment] – [Device used or no device] – [Assistance and guarding provided] – [Cueing type and reason]

• Temporal-spatial: [Step length asymmetry, cadence, stance time, base of support, path deviation]
• Foot/ankle: [Heel strike, foot slap, toe drag, clearance, push-off]
• Knee: [Hyperextension, inadequate flexion, instability]
• Hip/pelvis: [Trendelenburg, hip hiking, circumduction, reduced hip extension]
• Trunk: [Posture, lateral lean, arm swing, device positioning]
• Safety events: [Loss of balance, near-fall, improper device use] (Document context, triggers, and recovery)

Device Trials

(Repeat for each device trialed; maintain consistent format for comparability across trials)

Trial [number]: [Device type and key features]

• Fit/Setup: [Handle height setting] – [Accessories] – [Safety check: tips, brakes, wheels]
• Training Provided: [Skills instructed: sit-to-stand, sequencing, turning, thresholds, brakes, stairs] – [Method: demonstration, return demonstration, teach-back]
• Performance: [Distance] – [Assistance level] – [Cueing required] – [Gait quality compared to baseline] – [Notable deviations]
• Safety: [Stability] – [Loss-of-balance events] – [Device control issues: drift, roll-away, brake misuse]
• Patient Response: [Comfort, confidence, pain, fatigue, preference, acceptance]
• Clinician Interpretation: [One sentence summarizing trial outcome]

Devices considered but not trialed: [Device] – [Reason not trialed] (Include only if applicable; do not speculate on performance)

Patient/Caregiver Education

(Omit this section if all education is captured within device trials)

• Topics: [Education beyond device training: fall prevention, home safety, footwear, pacing]
• Recipient and method: [Patient and/or caregiver] – [Demonstration, teach-back, printed materials]
• Competency: [Verification method and areas needing reinforcement]

Assessment

Recommended Device: [Device or no device] – [Configuration: type, wheels, brakes, accessories] – [Fit parameters] – [Use parameters: indoor/outdoor, supervision level, stair restrictions]

Rationale: [Clinical justification referencing specific improvements observed during trials and connection to mobility-related activities of daily living. Include patient's demonstrated ability to manage the device safely.]

Problem Summary: [Key impairments] leading to [activity limitations] and [participation restrictions]

Safety Risk Summary: [Fall risk factors observed] – [Required supervision level and environments] – [Environmental constraints] – [Red flags requiring referral] (Include only if present)

Skilled Need: [Why device selection and training required skilled clinical judgment] (If recommending no device, document rationale and safety education provided)

Plan

• Next visit focus: [Progression targets: assistance reduction, cue reduction, complex surfaces, outdoor or community tasks]
• Home program: [Practice tasks, frequency, safety precautions] (Include only if provided)
• Device procurement: [Pathway: physician order, DME referral, patient to obtain] – [Responsible party and timeframe]
• Reassessment: [Specific measures to repeat and timeframe]

Missing Information

(Include only if critical information was not obtained and affected clinical decision-making)

[What was missing] – [Reason not obtained] – [Impact on session or recommendations]