Offloading Device Application Procedure Note (Total Contact Cast/Walker)

Date/Time: [Date and time of procedure]

Location: [Clinic/facility/service location]

Performing Clinician: [Name, credentials]

Laterality: [right / left]

Linked Diagnoses: [Diabetes-related foot ulcer diagnosis; neuropathy status; peripheral arterial disease status; infection status if applicable]

Procedure Summary

Procedure Performed: [Total Contact Cast (TCC) application / Removable Cast Walker (RCW/CAM walker) fitting / Non-removable walker conversion (iTCC)]

Indication: DFU offloading to promote ulcer healing

Ulcer Location: [plantar forefoot / plantar midfoot / plantar rearfoot / digit / non-plantar location]

Device Type: [knee-high non-removable / knee-high removable / ankle-high removable]

Weight-Bearing Status: [WBAT / partial weight-bearing / non-weight-bearing] [Assistive device if prescribed: cane / walker / crutches / wheelchair]

Complications: [none / list complications]

Clinical Context and Device Selection Rationale

[DFU context including onset/chronicity, recurrence history, prior offloading approaches and response] [Why escalation or intervention is indicated now] [Rationale for the specific device choice, addressing adherence history/concerns, wound inspection and dressing frequency needs, infection or ischemia considerations, fall risk, and patient constraints] [Clinical goal statement] (Required; format as 3-5 sentences. May reference a separate wound note for full measurements but must include sufficient justification for device choice.)

Pre-Procedure Assessment

(Explicitly document infection and perfusion findings; do not infer normal status from absence of documentation. If any safety-critical element cannot be assessed, document "not assessed" with reason and describe conservative mitigation taken.)

Ulcer/Skin Assessment: [Ulcer appearance relevant to offloading safety; exudate level and required dressing frequency; periwound skin condition; pressure-risk areas]

Infection Screen: [Local signs: erythema extent, warmth, swelling, tenderness, purulence; or "no clinical evidence of infection" with supporting findings; if infection present: severity category and impact on device choice and monitoring]

Perfusion/Ischemia: [Pedal pulses (palpable vs Doppler); capillary refill; skin temperature; recent vascular studies if available; PAD history/symptoms]

Neuropathy: [Protective sensation status and method if assessed]

Edema: [Current grade; stable vs fluctuating; impact on cast fit/safety]

Fall Risk and Mobility: [Baseline gait stability; assistive device use; home safety concerns; vision/balance issues]

Allergies/Sensitivities: [Adhesive sensitivity; latex allergy; prior cast-related skin issues] (Include if applicable)

Contraindications Review

[Contraindications reviewed; non-removable/knee-high device appropriate because (brief rationale)] or [Non-removable contraindicated because (reason); removable device selected] (Required. Review should address: infection/ischemia severity requiring frequent inspection, heavy exudate, unstable edema, inability to attend follow-up, high fall risk, limb deformity.)

Informed Consent

[Consent obtained for: TCC application / walker fitting / conversion to non-removable] [Benefits discussed: offloading to promote healing] [Material risks discussed: skin breakdown or pressure injury; unrecognized wound deterioration; infection progression if inspection limited; falls/gait instability; device loosening or failure; swelling-related constriction; need for urgent removal] [Alternatives discussed: removable device; footwear modifications; non-weight-bearing strategies] [Questions invited and answered; patient agreed] [If surrogate consent: name and relationship] (Required; specify risks discussed rather than stating only "risks discussed.")

Device and Procedure Details

Device: [Category: TCC / RCW/CAM walker / iTCC] [Height: knee-high / ankle-high] [Brand/model/size if applicable]

Interface/Modifications: [Insoles; offloading cutouts; padding strategy; felted foam placement if used]

For TCC: [Cast materials: stockinette, padding type/thickness, fiberglass or plaster, number of layers] [Wound dressing applied before casting] [Protective padding over bony prominences] [Cast molding approach and edge finishing] [Cast shoe applied and fit confirmed] [Valved or bivalved if applicable with rationale] (Include if TCC applied)

For Walker Fitting: [Sizing; strap adjustment; heel seating; insole/inlay used] [Patient trained on don/doff and securing straps] (Include if walker fitted)

For Non-Removable Conversion: [Method: wrap / cast tape / locking mechanism] [Removal plan: clinic only vs designated caregiver] [Inspection plan and frequency] (Include if iTCC conversion performed)

DME Dispensed: [Order/prescription generated; device provided with fitting and education] (Include if DME dispensed)

Post-Application Assessment

Neurovascular Status: [Capillary refill; skin color and temperature; pulses; sensation baseline; toe movement] [unchanged from pre-procedure / describe changes]

Fit and Pressure Check: [Patient-reported hot spots or insensate; toe space visible; cast margin comfort; no focal pressure areas]

Pain Assessment: [Pain rating] (Note if patient is insensate)

Tolerance: [Patient tolerated procedure well / issues encountered]

Immediate Complications: [none / complications with corrective actions]

(Required; do not omit.)

Gait, Safety, and Patient Education

Gait Evaluation: [Observed ambulation in device; stability and concerns] (If not assessed, document reason)

Assistive Device: [Cane / walker / crutches provided or used; training performed]

Limb-Length Discrepancy: [Contralateral shoe lift provided or recommended / not indicated and reason]

Weight-Bearing Instructions: [Instructions reinforced with patient]

Patient Education Documented:

• Wear schedule and adherence expectations [for removable: during all weight-bearing / for non-removable: do not remove or tamper]
• Warning signs requiring immediate return: [increasing pain/tightness; numbness/tingling/burning; excessive swelling; inability to move toes; discoloration or cool toes; foul odor or drainage through device; device cracking/loosening; new rubbing or sores at edges]
• Care instructions: [keep dry; do not insert objects; protect edges; elevate for swelling if instructed]
• Falls prevention: [use assistive device; slow turns; avoid uneven surfaces; stair strategy; nighttime lighting]
• How and when to seek urgent help: [contact information and return triggers]
• Understanding confirmed: [teach-back performed / patient verbalized understanding / caregiver involvement]
• Adherence barriers: [none identified / barriers and mitigation plan] (Include if applicable)

Follow-Up and Orders

Follow-Up Plan: [Specific interval for cast/wound check; next appointment date/timeframe] [What will be assessed: ulcer status, skin integrity, device fit, neurovascular check] (Required)

Cast Change Plan: [Next change date; who will perform] (Include if TCC applied)

Escalation Criteria: [When to switch device type; when to pause offloading for infection/ischemia management; when to refer urgently]

Orders Placed: [Wound care supplies; antibiotics; imaging; vascular referral; PT for gait training; home health; DME order; contralateral lift] (Include orders as applicable)

Related Notes: [Cross-reference wound assessment, debridement, or infection workup notes] (Include if applicable)

Procedure Completion

Condition on Discharge: [Ambulatory with device / wheelchair / caregiver present / other]

Electronic Signature: [Name, credentials, date/time]