Lower Limb Prosthesis Delivery Note (Definitive)

Patient Information

Patient: [Patient name] | DOB: [Date of birth] | MRN: [Medical record number]
Date of Service: [Delivery date] | Location: [in-clinic / inpatient / home / other: specify]
Prosthetist: [Name, credentials, facility]
Laterality/Level: [e.g., Right transtibial / Left transfemoral / Bilateral: specify]

Visit Summary

[Brief delivery summary] (State this is a definitive lower-limb prosthesis delivery. Include primary indication/diagnosis, current mobility context such as assistive devices, therapy involvement and activity restrictions, and patient goals if stated. Limit to 2–4 sentences.)

Order & Authorization

(Include this section when applicable to workflow; omit entirely if not applicable.)

• Standard Written Order: [present / pending—will update via addendum]
• Prior authorization: [approved / not required / pending—will update via addendum]
• Delivered configuration matches order: [yes / no] (If no, describe deviations and clinical rationale.)

Prosthesis Delivered

(List all major components with manufacturer, model, size, and serial number where applicable. If serial number is not yet available, enter "pending—will update via addendum.")

• Socket: [Design] | [Material/lamination] | [Interface details] | [Volume management features if any]
• Suspension: [Type: pin lock / suction / elevated vacuum / sleeve / other] | [Manufacturer/model if applicable]
• Foot: [Manufacturer] | [Model] | [Category/size] | [Serial number]
• Knee: [Manufacturer] | [Model] | [Size/config] | [Serial number] (Include only if applicable.)
• Liner: [Type/material] | [Size] | [Length] | [Serial number if serialized]
• Interface items provided: [Prosthetic socks: ply range and quantity] | [Sleeves: size/qty] | [Sealing rings: size/qty]
• Accessories: [Charger / cosmetic cover / tools / remote or app access / other] (Include quantities and identifiers where relevant.)

Fit & Alignment

Static alignment:

• Pelvic levelness: [level / slight drop R/L]
• Leg length: [equal / discrepancy: specify side and estimate]
• Foot contact: [flat / heel bias / toe bias]
• Socket comfort in standing: [comfortable / tolerable / uncomfortable: location/description]
• Suspension integrity: [secure / intermittent / inadequate] — [testing method]
• Safety checks: [Fasteners, locks, ROM stops, alignment screws, vacuum seal, knee function, foot appropriateness, footwear compatibility] (Note any issues and resolutions.)
• Residual limb volume: [stable / fluctuating] | Sock ply at start: [value]
• Baseline pain: [value/10 and location] (Include if relevant.)

Dynamic alignment:

• Walking trial conditions: [Assistive device, surfaces, footwear, distance/time tolerated]
• Observed gait deviations: [Description of clinically relevant deviations]
• Adjustments made: [Alignment/programming changes and immediate effect]
• Final alignment outcome: [Patient-reported comfort/stability and prosthetist-observed stability, clearances, rollover quality] (Note any accepted deviations with rationale.)

(If walking not performed, document reason and alternative assessment conducted.)

Microprocessor components: (Include only if applicable.)

• Modes configured: [Level ground / ramp / stair / stumble recovery / user profiles]
• Calibration performed: [Initialization procedures, heel height, sensitivity thresholds]
• Patient demonstrated charging and alert response: [yes / needs further training]

Skin Integrity

Pre-wear (arrival): [Intact / existing irritation: location and description]

Post-trial (after in-clinic wear): [Findings including location, severity, and whether expected/acceptable vs concerning] (Document actions taken: sock ply changes, padding, modification, wear-time limitations advised.)

Functional Performance

Donning/Doffing:

• Independence level: [independent / supervision / min assist / mod assist / max assist]
• Method: [Suspension sequence, liner-socket interface, sealing/valve use, lock engagement]
• Competency: [confirmed via return demonstration / partial / not achieved] (If not achieved, document barriers and plan.)

Mobility tasks observed: (Document only tasks performed; include device, surface, and assistance level.)

• Transfers: [Task: bed-chair / sit-stand] — [Assistance level] — [Observations]
• Standing balance: [Static/dynamic] — [Assistance level] — [Observations]
• Level ambulation: [Distance/time] — [Assistive device] — [Gait quality/effort]
• Environmental challenges: [Ramps / curbs / stairs / uneven surfaces] — [Assistance level] — [Observations] (Include only if tested.)

Standardized measures: (Include if performed.)

• [Test name: TUG / 10MWT / 6MWT / AMPPro / other] — [Result] — [Conditions: device/footwear/surface]

Patient/Caregiver Education

(Document training provided, modality, and competency. Note recipient: patient and/or caregiver.)

• Don/doff technique: [verbal / demonstration / written] — [competency: confirmed / partial / not achieved]
• Wear schedule & break-in: [verbal / demonstration / written] — [competency status]
• Skin inspection & warning signs: [verbal / demonstration / written] — [competency status]
• Residual limb hygiene & liner/sock care: [verbal / demonstration / written] — [competency status]
• Volume management: [verbal / demonstration / written] — [competency status]
• Device care & maintenance: [verbal / demonstration / written] — [competency status]
• Troubleshooting & when to contact: [verbal / demonstration / written] — [competency status]
• Follow-up expectations: [verbal / written] — [competency status]

(If competency not achieved for any element, document barriers and mitigation plan.)

Supplies Dispensed

[Itemized list: prosthetic socks with ply and quantity, extra liners, sleeves, adhesives, tools, spare parts] (If none, state: No additional supplies dispensed.)

Assessment

[Summary of fit acceptability, comfort, and alignment status. Immediate functional status including assistive device and safety profile. Specific limitations or risks identified such as fall risk, skin concerns, or device management issues. Current readiness level statement.] (Limit to 2–4 sentences. Base conclusions on documented observations.)

Plan

• Break-in schedule: [Hours/day progression, activity restrictions, signs to stop use]
• Follow-up: [Scheduled date or timeframe] — [Anticipated needs: volume adjustment, alignment refinement, programming]
• Therapy coordination: [PT/OT referral or communication and goals] (Include if applicable.)
• Red-flag instructions: [Skin breakdown, device malfunction, falls, pain escalation—when to stop use and contact clinic]

Proof of Delivery

• Patient name: [Name]
• Delivery location: [in-clinic / inpatient / home / other: specify]
• Item(s) delivered: [Device/component/supply descriptions and quantities]
• Date delivered: [Date]
• Recipient signature: [Patient or designee signature] | Relationship: [If designee] | Date/Time: [Timestamp]

(If signature cannot be obtained, document reason and alternative compliance process.)

Signature

Prosthetist: [Name, credentials] | Signature: [Electronic/handwritten] | Date/Time: [Timestamp]

(Any corrections or additions must be documented as clearly labeled addenda preserving original content.)