Lymphedema Evaluation & Treatment Note

Date of Service: [Date]

Patient Name: [Full name]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Clinician: [Name, credentials, certifications (e.g., CLT)]

Referring Provider: [Name, credentials]

Primary Diagnosis: [ICD-10 code and description]

Precautions/Contraindications: [Safety concerns and risk factors] (Prominently list items such as history of cellulitis/lymphangitis, DVT/PE, CHF, CKD, arterial disease, neuropathy, skin fragility, adhesive allergies, or active infection. If unknown or not assessed, state "Not assessed" only when this information would normally be expected for safety.)

Note Type: [Initial Evaluation / Daily Treatment Note / Re-evaluation / Progress Report / Discharge Note]

(Only include sections relevant to the specified Note Type. Omit non-applicable sections rather than leaving empty fields.)

Reason for Visit

[Chief concern and visit objective] (Concise statement of the patient's main concern and the visit's purpose, e.g., evaluation for staging, garment fitting, Phase I decongestion, maintenance optimization, or flare management. May include a brief patient quote.)

Subjective

(For Initial Evaluation/Re-evaluation, complete the detailed history below. For follow-up Treatment Notes, focus on interval changes since last visit, adherence, and new symptoms; do not repeat unchanged historical details.)

• Onset and Course: [Onset timing, chronicity, progression pattern]
• Triggering Events: [Surgery, lymph node dissection, radiation, trauma, infection, travel, other]
• Distribution: [Regions involved: limb/trunk/breast/genital/head-neck; laterality]
• Fluctuation/Response: [Diurnal variation; response to elevation/compression; aggravating/alleviating factors]
• Infection History: [Prior cellulitis/lymphangitis episodes, frequency, last occurrence, treatment]
• Prior Treatments and Adherence: [Prior CDT/MLD/compression/garments; adherence barriers; tolerance/intolerance]
• Current Symptoms: [Heaviness; tightness; pain (location, quality, 0–10); paresthesia; skin changes; drainage]
• Functional Impact: [ADLs, work, gait, sleep, psychosocial]
• Patient Goals: [Goals in patient's own words]
• Red Flag Screen: [Fever/chills; rapidly spreading erythema; sudden calf pain/swelling; acute dyspnea/chest pain] (If any positive, document actions taken and escalation/consultation.)
• Targeted Medical History: [Cancer/treatments; vascular disease; heart failure; renal disease; diabetes; dermatologic conditions; medications affecting edema; caregiver support for compression management]
• Interval Changes (Follow-up only): [Changes in swelling/symptoms; adherence; new issues since last visit]

Objective

(Document only clinician-observed or measured findings.)

• Integumentary and Tissue Assessment:
  • [Skin integrity: intact / breaks / maceration / fissures / hyperkeratosis / papillomatosis / weeping]
  • [Color/temperature/tenderness: erythema, warmth, hemosiderin staining]
  • [Edema quality: pitting grade, soft vs fibrotic, induration, peau d'orange]
  • [Stemmer sign: positive / negative / not assessed]
  • [Fibrosis locations; skin folds; lobules]
  • [Scar adherence; radiation skin changes] (if relevant)
  • [Hygiene/nail care risk factors]
  • (If bandages not removed or assessment limited, state limitation and reason.)
• Lymphedema Staging:
  • Staging System: [ISL / other]
  • Assigned Stage: [Stage 0 / Stage I / Stage II / Stage III]
  • Supporting Clinical Findings: [Specific exam findings that justify the stage, e.g., "swelling reduces with elevation, no fibrosis" for Stage I or "swelling does not reduce with elevation, pitting present, fibrosis at distal forearm" for Stage II] (Required—do not assign a stage without documenting the clinical criteria that support it.)
  • Severity: [Percent volume difference vs contralateral or baseline] (optional)
  • (If staging cannot be determined, state "Stage not determined—insufficient data" and specify what is missing.)
• Measurements:
  • Method: [Circumferential tape / perometry / water displacement / BIS-BIA]
  • Position: [Patient position and limb support]
  • Landmarks: [Anatomical landmarks and interval scheme used]
  • Circumferential Measurements: [Affected vs unaffected or current vs baseline] (Provide tabulated values or concise list sufficient for reproducibility.)
  • Volume Calculation: [Volume and method] (if performed)
  • [Region-appropriate measures for trunk/breast/genital/head-neck] (if applicable)
  • (If only targeted fit-check performed, document only relevant measurements.)
• Vascular and Neurologic Screen: (When applicable, especially lower extremity)
  • [Arterial status: pedal pulses, capillary refill, ABI/toe pressures if available]
  • [Sensation/neuropathy relevant to compression tolerance]
  • [Pain or findings concerning for ischemia]
  • (If not performed, document why and note compression modifications until clearance is obtained.)
• ROM, Strength, and Function:
  • [Range of motion and strength relevant to limb function and garment donning/doffing]
  • [Gait/balance/safety considerations]
  • [Validated functional outcome measures and scores] (if used)

Assessment

Clinical Impression: [Lymphedema classification (primary vs secondary), suspected contributing factors, differential considerations for atypical presentations]

Problem List: (Address applicable problems in order of clinical priority)

• Lymphedema volume/swelling: [Stage and key measurement summary]
• Skin integrity and infection risk: [Primary risks, current findings]
• Pain/sensory symptoms: [Location, quality, severity] (if present)
• Functional limitations: [Impacted activities and safety] (if present)
• Self-management barriers: [Donning/doffing ability, caregiver support, knowledge gaps] (if present)

(For Treatment Notes, include response to today's interventions with measurable or observable changes. If progress is limited, document barriers and rationale for continued skilled care.)

Prognosis: [Good / Fair / Poor] [Rationale]

Goals:

• Short-term goals ([timeframe]): [Measurable goals, e.g., volume reduction %, improved donning independence, symptom reduction]
• Long-term goals ([timeframe]): [Measurable goals, e.g., maintenance targets, absence of cellulitis episodes, recognition of warning signs]

Plan

Plan of Care: (For Evaluations/Re-evaluations)

• Phase of Care: [Phase I intensive decongestion / Phase II maintenance]
• Frequency and Duration: [Visits per week, total weeks/visits]
• Planned Interventions: [Manual lymphatic drainage, compression bandaging/wrapping, therapeutic exercise, skin care, patient education]
• Monitoring Plan: [Re-measurement schedule, outcome tools]
• Care Coordination: [Provider communication, DME vendor coordination, referrals]

Compression Plan: (Medical necessity documentation—critical for DME orders)

• Current Phase and Objective: [Decongestion / maintenance]
• Compression Modality: [Multilayer short-stretch bandaging / adjustable wraps / daytime gradient garment / nighttime garment / combination]
• Garment Specifications: [Body region; laterality; type; ready-to-wear vs custom; compression class; style/features; accessories (donning aids, padding, liners, chip pads)] (when ordering)
• Medical Necessity Rationale: [Limb shape distortion, skin folds, fibrosis, failure to maintain reduction with alternatives, intolerance of other options, need for nighttime containment]
• Wear Schedule and Precautions: [Hours per day, activity modifications, skin monitoring]
• Follow-up Plan: [Fit check timing, replacement schedule]
• (If compression is deferred, document why and describe interim management.)

Patient Education and Self-Management:

• Topics Covered: [Chronicity of condition, skin care, infection prevention/recognition, activity guidance, travel considerations]
• Skills Trained: [Self-MLD, bandaging/wrap application, garment donning/doffing, daily skin inspection]
• Patient Demonstration: [Teach-back performance and remaining training needs]

Treatment Performed Today

(Include for Daily Treatment Notes and as applicable during Evaluations/Re-evaluations.)

• Interventions: [MLD areas treated and sequence; compression materials and padding used; therapeutic exercises (type, sets/reps); skin care provided]
• Parameters: [Technique details, pressures if applicable, hold times, repetitions]
• Time: [Total treatment time]; [Timed-code minutes by intervention/CPT code]
• Pre/Post Measures: [Circumference points or volume; symptom ratings; functional measures]
• Tolerance/Adverse Events: [Patient tolerance; any adverse events and actions taken]
• Education Today: [Content covered and patient response]
• Plan for Next Visit: [Planned progressions or modifications; measurement checkpoints]

Progress Report

(Include only when documenting a formal progress update, per Medicare requirements every 10 treatment days or 30 calendar days.)

• Reporting Period: [Start date] – [End date]
• Goal Progress: [Each goal with baseline → current comparison and objective measures]
• Updated Stage/Severity: [Stage with supporting findings; updated measurements/volumes]
• Clinical Determination: [Continue / Modify / Discharge] [Rationale]
• Plan of Care Revisions: [Updated frequency/duration/interventions/compression plan]

Discharge Summary

(Include only for discharge.)

• Reason for Discharge: [Goals met / Plateau / Patient choice / Transfer of care / Other]
• Final Status: [Key measurements/volume; skin condition; functional status]
• Current Compression Plan: [Garment type/specs; wear schedule; replacement timeline; follow-up instructions]
• Self-Management Competency: [Patient/caregiver independence with donning/doffing, self-MLD, skin checks]
• Return Precautions: [When to seek urgent care (e.g., infection signs, acute worsening) and when to return to therapy]

(When documenting clinical labels such as stage or severity, always include supporting examination findings. Measurements must be reproducible with method, landmarks, and position documented. Use "Not assessed" only for items normally expected for safety or quality.)