Lower-Limb Prosthetic Initial Evaluation (Pre-Prosthetic)

Date of Service: [Date of service]

Location: [Clinic or facility location]

Visit Type: Initial Evaluation

Patient Name: [Patient full name]

DOB: [DOB]

Referring Provider: [Referring provider name and credentials] | [Order status: current order present / order pending / no order on file]

Author/Credentials: [Author name and credentials]

Reason for Evaluation

[Chief concern in patient's own words, focusing on functional goals, pain, safety, and participation priorities]

This is a pre-prosthetic initial evaluation to assess prosthetic candidacy, characterize current function and expected potential, examine the residual limb, and propose a staged prosthetic plan.

History

(Provide concise narrative prioritizing information relevant to prosthetic candidacy, safety, and design decisions. Use "Unknown/not reported" where appropriate and note plans to obtain missing information.)

• Amputation History: [Side] [Level] | [Date of amputation] | [Etiology: dysvascular/diabetic / trauma / infection / malignancy / congenital] | [Wound healing status] | [Revisions or complications] | [Current limb management: shrinker/compression use, skin checks] | [Prior prosthetic history if applicable: socket types, suspension, reasons for success or abandonment]
• Relevant Medical History: [Conditions affecting healing/skin integrity: diabetes, PAD, edema/CHF, renal disease] | [Cardiopulmonary/endurance limitations] | [Cognition, vision, or neuropathy affecting safety] | [Contralateral limb status: ulcers, deformity, neuropathy]
• Pain and Sensation: [Residual limb pain characteristics] | [Phantom limb pain/sensation] | [Suspected neuroma symptoms] | [Proximal joint or back pain] | [Severity, triggers, current treatments, response]
• Functional Status: [Pre-amputation mobility and community participation] | [Current transfers, wheelchair mobility, ambulatory attempts] | [Falls history] | [ADL/IADL limitations] | [Assistive devices used] | [Assistance level required]
• Rehabilitation to Date: [PT/OT involvement and intensity] | [Key progress: strength, balance, transfers] | [Home exercise adherence] | [Barriers]
• Social and Environmental Factors: [Home setup: stairs, surfaces, bathroom access] | [Caregiver support] | [Transportation] | [Work/vocational demands] | [Patient preferences: cosmesis, footwear, activity priorities]
• Goals: [Near-term pre-prosthetic goals: edema control, contracture prevention, transfer safety] | [Prosthetic functional goals: household vs community ambulation, terrain needs, return-to-work] | [Risk tolerance regarding falls and energy expenditure]

Objective Examination

(Use structured bullets and short phrases. Reserve full sentences for unusual findings or safety events. If a relevant element was not assessed, document as "Not assessed [reason]" and include plan to address.)

• General: [Appearance] | [Endurance during visit] | [Cognition and safety awareness] | [Method of arrival: wheelchair / walker / ambulating; assistance level] | [Vital signs if cardiopulmonary comorbidity present or locally required]
• Residual Limb Examination:
  • Skin/incision: [Integrity] | [Healing status] | [Scar mobility and adherence] | [Sensitivity] | [Signs of infection or breakdown]
  • Shape/volume: [Conical / cylindrical / bulbous] | [Edema presence and pattern] | [Volume stability] | [Compression device use]
  • Bony anatomy: [Prominences] | [Distal end tolerance] | [Pressure-sensitive areas]
  • Soft tissue: [Density and pliability] | [Redundant tissue] | [Tenderness]
  • Sensation: [Protective sensation] | [Neuropathy] | [Hypersensitivity or allodynia]
  • Circulation: [Temperature] | [Color] | [Capillary refill] | [Trophic changes] (Include when vascular disease present or clinically relevant.)
• Range of Motion: [Hip ROM] | [Knee ROM as applicable to level] | [Contralateral limb ROM] | [Contractures: degrees, fixed vs flexible] | [Spine/hip ROM if affecting gait or component selection]
• Strength: [Hip extensors and abductors] | [Core stability] | [Contralateral limb] | [Upper extremity relevant to assistive devices and transfers]
• Contralateral Limb: [Skin integrity, especially plantar] | [Deformities] | [Neuropathy] | [Pain] | [Footwear issues]
• Balance and Coordination: [Sitting balance] | [Standing balance] | [Protective reactions] | [Vestibular or coordination issues]
• Functional Performance Measures: [Test name] | [Conditions: device used, assistance level, surface] | [Score/time/distance] | [Clinical interpretation] (Select measures feasible pre-prosthetically: AMP no-prosthesis version, TUG, 10MWT, 2MWT/6MWT if ambulatory, patient-reported measures as baseline.)
• Current Equipment: [Wheelchair type and configuration] | [Ambulatory aids] | [Compression devices] | [Footwear]

Assessment

Summary: [Amputation level and side] | [Key comorbidities] | [Residual limb readiness status] | [Current mobility baseline] | [Major limiting factors] | [Patient goals] (One concise paragraph synthesizing the case.)

Problem List: (Order by severity and impact. Include brief clinical reasoning for each.)

• [Problem 1]: [Brief rationale]
• [Problem 2]: [Brief rationale]
• [Problem 3]: [Brief rationale]
• (Add or remove items as clinically appropriate.)

Current Functional Capability: [What the patient can do now, with what assistance and devices]

Expected Functional Potential: [Reasonable expectations after rehabilitation and prosthetic training] (Provide brief rationale tied to exam findings and trajectory; note limiting factors such as contracture or cardiopulmonary ceiling.)

Functional Level Classification: [K0 / K1 / K2 / K3 / K4] (Assign expected functional level with explicit justification based on: objective performance measures, observed transfers/balance/gait, endurance, comorbidities, safety constraints, patient goals, and typical environment. For atypical cases such as bilateral amputees, explain how classification was derived.)

Risks and Mitigation: [Applicable risks: falls, skin breakdown, contralateral overuse, cardiopulmonary limitations, infection] | [Mitigation strategies: targeted therapy, wound care, education, staged fitting]

Prosthetic Plan

• Prosthetic Pathway: [Recommended phase: preparatory/temporary vs definitive] | [Rationale] | [Readiness status: ready for casting/scanning / not ready] | [Prerequisites before proceeding: wound closure, volume stabilization, contracture improvement]
• Preliminary Prescription Concepts: [Socket concept and interface] | [Suspension concept based on limb characteristics and patient factors] | [Component class rationale: stability vs mobility, terrain needs, safety features] (High-level concepts only. Document when advanced components are considered but deferred pending healing or training response.)
• Medical Necessity: [How plan addresses mobility and independence] | [Fall/injury risk reduction] | [Environmental demands] | [Realistic endurance constraints] (Avoid unsupported inferences.)
• Timeline and Milestones: [Prerequisites: wound healed, edema controlled, ROM targets] | [Expected timeframe for casting/scan] | [Test socket] | [Delivery] | [Gait training initiation] | [Follow-up schedule]
• Interdisciplinary Coordination: [Next steps by provider: treating practitioner order, PT/OT plan, surgeon follow-up, wound clinic] | [Information to request from other clinicians]
• Patient Education and Agreement: [Education provided: skin checks, volume management, positioning, realistic expectations] | [Patient understanding and agreement] | [Barriers to learning or adherence]
• Contingencies: If [wound deterioration] then [pause fabrication and address wound]. If [contracture prevents safe alignment] then [initiate stretching/orthoses before fabrication]. If [training progress fails to meet expected potential] then [reassess and revise plan/components].

Follow-Up

• Action Items: [Specific next steps] | [Responsible parties] | [Target dates]
• Referrals: [PT/OT / Wound care / Vascular / Pain management / Other services as indicated]
• Return Precautions: [Triggers for urgent contact: new wound drainage, erythema, fever, rapid pain increase, new falls]

(Documentation standards: Avoid undocumented assumptions about motivation, cognition, or ambulatory potential. Use "Not assessed [reason]" or "Unknown/not reported" rather than leaving items blank. Functional level classification requires explicit rationale with objective support. Inferences about expected potential must be supported by exam findings and observed trajectory.)