Lower-Limb Prosthetic Functional Level Assessment (K0-K4)

Date/Time: [Date and time of assessment]

Location/Setting: [Clinic / inpatient unit / home / other]

Author: [Author name, credentials, and role]

Patient Name: [Patient full name]

DOB: [Date of birth]

MRN: [Medical record number]

Amputation Side and Level: [Left / Right / Bilateral] [Transmetatarsal / Transtibial / Knee disarticulation / Transfemoral / Hip disarticulation / Other]

Referring Clinician: [Name and credentials]

Reason for Assessment: [Functional level determination for definitive prosthesis / Re-evaluation / Component upgrade justification / Other]

Assessment Context

[Purpose of assessment] (State that the assessment determines current functional status, prior functional level, and anticipated functional potential to support Medicare K-level selection.) [Sources of information used] (List sources such as patient report, caregiver input, prior therapy notes, prosthetist notes, hospital records. Note any reliability concerns such as cognitive limitations, communication barriers, or inconsistent history.)

• Episode timing: [Pre-prosthetic / Preparatory phase / Definitive prosthesis evaluation / Re-evaluation]
• Assessment conditions: [With prosthesis / Without prosthesis / Partial session with and without]
• Current prosthesis: [Type and components] (Only include if applicable)
• Assistive devices used during testing: [None / Cane / Walker / Crutches / Wheelchair follow]
• Surfaces/environments tested: [Level surface / Carpet / Tile / Outdoor / Ramp / Uneven terrain / Parallel bars]

Medical and Prosthetic History

• Amputation history: [Etiology] | [Date or timeline] | [Surgical level] | [Healing course and complications] | [Functional implications]
• Residual limb status impacting wear: [Skin integrity issues] | [Volume fluctuation] | [Pain] | [ROM limitations] | [Socket tolerance] | [Impact on donning time, wear time, and gait]
• Key comorbidities with functional implications:
  • [Condition] – [Specific impact on mobility, endurance, balance, or safety]
  • (Add additional conditions only as relevant to function)
• Prosthetic history: [Prior prosthesis type and components] | [Dates of use] | [Wear schedule] | [Tolerance and complications] | [Reason for discontinuation if applicable] (State "No prior prosthesis use" if none)
• Prior Level of Function (PLOF): [Household vs community ambulation] | [Typical distances] | [Stairs, curbs, terrain ability] | [Assistive devices used] | [Fall history] (If PLOF cannot be confirmed, state that records were requested and from where)

Current Functional Status

Self-Reported Function

• Current mobility mode: [Wheelchair dependence / Limited household ambulation / Community ambulation] | [Prosthesis wear frequency and duration]
• ADLs/IADLs affected: [Activities affected and assistance required]
• Community participation: [Frequency of leaving home] | [Transportation method]
• Self-reported tolerance: [Stairs] | [Curbs] | [Uneven terrain] | [Ramps]
• Falls/near-falls: [Frequency] | [Circumstances] | [Injuries]

Observed Functional Performance

(Document tasks using format: task + conditions + assistance level + quality)

• Transfers: [Sit-to-stand] | [Surface height and armrests] | [Assistance level: Independent / Supervision / CGA / Min A / Mod A / Max A] | [Quality and safety observations]
• Gait on level: [Device used] | [Base of support] | [Step length and symmetry] | [Foot clearance] | [Stance stability and prosthetic knee control] | [Turning] | [Assistance level] | [Quality descriptors]
• Cadence control: [Ability to vary speed on command] | [Start/stop control] | [Response to obstacles]
• Environmental barriers: [Curb step] | [Stairs with rail / without rail; step-to vs reciprocal] | [Uneven surfaces] | [Ramp] | [Doorway negotiation] | [Assistance level and quality]
• Endurance: [Distance ambulated] | [Number and duration of rest breaks] | [Signs of exertion: dyspnea, RPE, HR/BP response] | [Reason for stopping]
• Safety observations: [Losses of balance or near-falls] | [Need for guarding] | [Hazard awareness and device management]
• Tasks not assessed: [Task] | [Reason: medical risk / safety concern / time constraint] | [Surrogate information used] (Only include if applicable)

Standardized Outcome Measures

(Include tests performed. If no standardized testing was performed, omit this subsection or briefly state the reason and that K-level determination was based on observed tasks and chart review.)

• [Test name]: [Score] | [Date] | [Conditions: with/without prosthesis, device used] | [Interpretation related to K-level]
• (Common measures: Amputee Mobility Predictor, Timed Up and Go, 10-Meter Walk Test, 6-Minute Walk Test, Berg Balance Scale)

Physical Examination

(Include only findings relevant to prosthetic use and K-level determination. Omit normal findings that do not affect classification.)

• Residual limb: [Skin integrity] | [Edema/volume] | [Pain/tenderness] | [ROM relevant to gait] | [Scar adherence] | [Functional implication]
• Contralateral limb: [Wounds/ulcers] | [Neuropathy] | [Strength/ROM limitations] | [Footwear/orthotics] | [Functional implication]
• Strength/ROM: [Hip extensors/abductors] | [Knee extensors/flexors] | [Core/trunk] | [Impact on stance stability and propulsion]
• Balance: [Static/dynamic balance findings] | [Single-limb tolerance] | [Protective reactions] | [Assistance level required]
• Cardiopulmonary tolerance: [Vitals response to exertion] | [Dyspnea/fatigue threshold] | [Activity limitations]
• Cognition/vision: [Attention, command following, insight, memory] | [Visual acuity/field] | [Ability to manage device/components] (Only include if affecting safety or device management)

Environmental Demands and Goals

• Home setup: [Entry steps/thresholds] | [Stairs and rails] | [Bathroom layout/grab bars] | [Assistance availability] (Note whether verified or patient-reported)
• Community barriers: [Transportation] | [Sidewalks/curbs] | [Typical terrain] | [Weather considerations]
• Work/school demands: [Standing/walking requirements] | [Distances/stairs] | [Carrying loads] | [Safety requirements] (Only include if applicable)
• Recreational goals: [Activities] | [Environmental demands] | [Frequency]
• Motivation and engagement: [Patient's expressed desire to ambulate] | [Demonstrated participation and adherence] (Include brief direct quote if it strengthens the record)
• Patient-centered goals: [Short-term goals] | [Long-term goals]
• Rehabilitation trajectory evidence: [Response to therapy/training] | [Learning ability] | [Prior prosthesis success] | [Support systems]
• Barriers to progression: [Barrier] – [Plan to address] (Only include if barriers identified)

K-Level Determination

Selected Functional Level: [K0 / K1 / K2 / K3 / K4]
Represents: [Current functional level / Anticipated potential within rehabilitation timeline / Both current and anticipated]

Key criterion matched: [Non-ambulatory candidate (K0) / Fixed cadence, household ambulator (K1) / Limited community ambulation with environmental negotiation (K2) / Variable cadence, community ambulator (K3) / High-impact or high-load demands (K4)]

• Supporting evidence:
  • [Specific observation, test result, or history element tied to criterion]
  • [Additional supporting evidence]
  • (Include 2-5 items as available)
• Why next lower level does not apply: [Rationale tied to criteria and evidence]
• Why next higher level does not apply: [Rationale tied to criteria and evidence]

Current vs anticipated potential: [If different, state expected improvement, basis (prior function, exam findings, training response), and expected timeline. Document objective clinical basis; do not base potential solely on age or stated desire.] (Only include if current function differs from anticipated potential)

(For bilateral amputees, include narrative explaining how standard K-level categories are applied and justify classification with functional evidence.)

Advanced Component Justification

(Only include this section when recommending advanced knee or foot/ankle technology, including for K2 patients requiring fluid, pneumatic, electronic, or microprocessor-controlled components. Omit entirely if not applicable.)

• Component recommendation: [Specific knee/foot/ankle technology and model/features]
• Health and safety context: [Fall risk factors] | [Endurance constraints] | [Cognitive/vision considerations for safe use]
• Expected functional outcomes: [Fall reduction] | [Energy conservation] | [ADL/IADL improvements] | [Environmental negotiation]
• Why lower-level components are insufficient: [Documented needs not met by non-microprocessor or non-fluid/pneumatic options]
• User management capacity: [Ability to charge, manage alerts, and maintain device] (Only include for microprocessor/electronic components)
• Feature-to-need mapping:
  • [Technology feature] – [Specific functional need and scenario addressed]

Recommendations and Plan

• Recommended K-Level: [K0 / K1 / K2 / K3 / K4] | [Current / Anticipated / Both] (Include timeline if applicable)
• Prosthetic training: [Therapy focus areas] | [Frequency and duration]
• Fall prevention: [Interventions and education] | [Home safety actions]
• Assistive devices: [Device recommendations] | [Temporary vs long-term use] | [Fit/training plan]
• Follow-up and reassessment: [Timeframe for reevaluation] | [Outcome measures planned] | [Coordination with prosthetist/therapy]
• Referrals: [Wound care / Cardiology / OT / Behavioral health / Other as indicated] (Only include if referrals made)