Orthotics & Prosthetics Device Delivery Note

Date of Service: [Date (YYYY-MM-DD)]

Start/End Time: [Start time – End time] (Include only when substantial training provided.)

Patient Name: [Patient full name]

DOB: [Date of birth] and/or MRN: [Medical record number]

Delivery Address: [Address] (Include if different from demographics or relevant for POD.)

Clinician: [Name, credentials, role (e.g., CPO/CO/CP)]

Location: [clinic / inpatient facility / home visit / shipping-mail]

Visit Type: [in-person delivery / shipping / initial / replacement / exchange]

Prescription/Order Reference

• Ordering clinician: [Name]
• Order date or identifier: [Date or order ID]
• Diagnosis/indication: [Primary diagnosis/indication relevant to device]
• Side/level: [left / right / bilateral / level]
• Conformance statement: [Delivered configuration matches order / Variance from order: (describe) and prescriber notified (how/when) / Order not accessible at delivery—delivery proceeded per protocol, reconciliation pending]

Items Delivered

(List each device and its components. Repeat the block below for each item delivered.)

• Item: [Item type and common name] | Side/Level: [Side/level] | Quantity: [#] | Condition: [new / replacement / warranty exchange / loaner / temporary]
  • HCPCS code(s): [Code(s) with modifiers if applicable]
  • Manufacturer/Model/Size: [Manufacturer, model, size / custom-fabricated]
  • Serial/Lot #: [Serial or lot number / not labeled]
  • Key components included: [List components such as liners, sleeves, sockets, joints, foot/knee units, control systems, chargers] (Include only components actually delivered.)
  • Accessories/Supplies delivered: [List accessories/supplies and quantities]

Pre-Delivery Status

(Document only what was observed or reported at this visit. If delivery/fitting deferred due to contraindication, document reason, what was delivered if anything, and interim plan.)

• Patient-reported status: [Pain level/location, recent skin issues or changes since last visit, relevant functional changes]
• Residual limb status: [Volume/edema, wounds, scar sensitivity, shape] (For prosthesis users.)
• Clinician-observed skin integrity: [Findings in device contact areas]
• Edema/sensation risk factors: [Edema level, neuropathy, other risks] (Include only if relevant.)
• Delivery/fitting deferral: [Not deferred / Deferred due to (reason); interim plan: (plan)]

Fit Verification and Adjustments

(For in-person delivery, document safety check, interface fit, alignment, suspension, and compatibility. For shipping/mail delivery, use the shipping statement and document training modality and follow-up plan instead.)

• Pre-use safety check: [Structural integrity intact / closures-straps-locks functional / electronics power on] (Document only what was performed.)
• Interface fit and pressure distribution: [Description of fit in contact areas]
• Alignment/positioning: [Alignment relative to anatomical landmarks; limb length/symmetry if applicable]
• Socket/suspension: [Fit, suspension type, outcome] (For prostheses.)
• Footwear/device compatibility: [Compatible footwear or requirements]
• Adjustments performed: [Modification type and rationale] | Post-adjustment outcome: [Outcome] (Omit if no adjustments made.)
• Shipping/mail delivery statement: "Delivered by shipping—fit verification not performed in-person on DOS." Training modality: [phone / video / written materials] | Follow-up plan for in-person verification: [Plan] (Include only for shipped items; omit fit verification fields above.)

Functional Trial and Skin Check

(Document only activities observed or explicitly reported during the visit. Omit section for shipped items.)

• Activities trialed: [Transfers / ambulation distance and surfaces / stairs or ramps / gait observations / upper-limb tasks] (Include only those performed.)
• Patient tolerance: [Tolerated well / limited by (reason)]
• Skin inspection after trial: [Findings; note any erythema and time to resolution]
• Patient acceptance: [Patient accepted device / Patient did not accept device: (reason) and next steps]

Patient/Caregiver Training

(Document all training provided. Do not omit skin inspection or safety counseling for custom-fitted items.)

• Donning/Doffing:
  • Training recipient: [patient / caregiver / both]
  • Method: [demonstration / verbal / written / video]
  • Competency validation: [independent return-demonstration / performed with assistance / not demonstrated: (reason)]
• Wear Schedule: [Individualized break-in plan] | Restrictions: [Specific limits, e.g., therapy sessions only, no community ambulation until cleared, do not sleep in device / no restrictions]
• Skin Inspection: [What to monitor: pressure areas, persistent redness, blistering, breakdown, pain, edema] | Threshold for action: [Stop wear and contact clinic if redness persists beyond (time) or skin breakdown occurs] | Reduced sensation: [Enhanced counseling provided / not applicable]
• Care and Maintenance: [Cleaning instructions for device and interface; drying/heat precautions; consumable replacement schedule; warning against self-repair for complex devices]
• Safety Counseling: [Fall risk and assistive device use; footwear guidance; water/electrical/heat cautions for powered components; driving/work/sport restrictions] (Include only applicable items.)
• Troubleshooting: [Common problems and actions; clinic contact information; stop-use conditions]
• Instruction confirmation: [Written instructions provided / patient verbalized understanding / teach-back performed / return-demonstration observed] (If caregiver training deferred due to absence, document and schedule follow-up.)

Follow-Up Plan

• Follow-up timeframe: [Timeframe] | Appointment: [scheduled / to be scheduled] | Modality: [in-person / telehealth]
• Purpose of follow-up: [fit re-check / alignment tuning / skin check / adjustment / other]
• Therapy coordination: [PT/OT referral placed / coordination with existing therapy / not required]
• Prescriber notification: [Notified of (findings) via (method) / not applicable]
• Patient instructions: [Track wear time, skin response, pain, falls, device issues] | Return sooner if: [Specific thresholds or concerns]

Proof of Delivery

(Required for billing and audit compliance. Do not leave POD fields blank; use "unknown" only when truly unknown and flag for operational follow-up.)

• Delivery Method: [direct handoff / shipping-mail / delivery to facility on behalf of beneficiary]
• Recipient: [Patient name / authorized designee: (name, relationship)] (Do not allow staff with financial interest in delivery to sign as designee.)
• Required POD Elements:
  • Beneficiary name: [Name]
  • Delivery address: [Address where actually delivered]
  • Date delivered: [Actual receipt date, YYYY-MM-DD]
  • Item description: [Description sufficient to identify what was delivered]
  • Quantity: [Quantity for each item]
• Signature/Confirmation:
  • Direct delivery: [Beneficiary/designee signature and date] | Printed name: [Name] | Relationship: [Relationship] (Record printed name and relationship if signature illegible.)
  • Shipping: [Carrier name] | [Tracking number] | [Delivery confirmation date/time/status]
  • Facility delivery: [Facility receipt documentation details]
• Inpatient discharge-day delivery: [Purpose was fitting/training; how device accompanies patient home; DOS aligns with discharge-day billing rules] (Include only if applicable.)
• Operational follow-up needed: [yes / no] | Items to resolve: [List any unknown POD elements and plan to obtain] (Omit if no follow-up needed.)

Attestation

Clinician signature: [Signature, credentials, date]

Attestation: Device(s) delivered as listed; training/instructions provided; fit and function [verified as documented above / not performed in-person (shipped item)]; follow-up plan provided.

(Meta-instructions: Do not infer fit verification, skin status, or patient competency—document only what was performed or observed. For shipped items, do not claim in-person verification occurred. Omit sections only when clearly not applicable to the device delivered; do not omit skin inspection or safety counseling for custom-fitted items.)