Orthotics & Prosthetics Device Fitting Procedure Note

Patient name, MRN, DOB: [Patient full name], [MRN], [DOB]

Date of service: [Date]

Location/clinic: [Clinic or facility name]

Clinician name and credentials: [Clinician name, credentials]

Others present: [Names and roles of therapists, caregivers, interpreter with language/modality] (Omit line if none present.)

Encounter type: [Check socket fitting / Trial orthosis fitting / Diagnostic fitting / Other]

Body region, laterality, and level: [e.g., Left transtibial, Right AFO, Cervical TLSO]

Device stage: [Diagnostic/test fitting / Definitive device]

Device Identification

[Device type and intended use] (Describe what was fitted today so it can be uniquely identified.)

• Interface elements: [Socket design or shell configuration, liner/interface, suspension method, padding, straps/closures, joints, shoe interface as applicable] (Include only elements relevant to device type.)
• Components trialed or swapped: [Components and configurations evaluated] (Identify by type or model when known. Omit if none.)

Reason for Visit

[Brief purpose of today's diagnostic fitting] (One to two sentences. If no interval history was obtained, state: "Interval history not obtained—focus of visit was technical fitting.")

[Interval history relevant to fit] (Patient-reported comfort issues, pain location/quality, instability, pistoning, skin concerns, tolerance time, falls/near-falls; medical or functional changes since last visit. Use direct quotes for key subjective descriptions. Omit paragraph if none obtained.)

Pre-Fitting Assessment

• Skin integrity and limb status: [Inspection findings] (Residual limb or segment findings including erythema, blister, open areas with location/size if abnormal; edema or volume observations; sensation concerns. If not performed, state: "Skin inspection not performed—[reason].")
• Baseline function: [Transfers, standing tolerance, assistive device used, supervision level]

Fitting Procedure

Donning and Setup

• [Donning/doffing ability, assistance required, education provided]
• [Interface configuration] (Sock ply, liner size, volume management elements.)

Static Fit Assessment

• [Trimline height and range of motion clearance]
• [Total contact and volume accommodation] (Gapping, bottoming out, excessive pressure.)
• [Suspension and stability] (Pistoning, rotation, migration, strap security.)
• [Device position and bench alignment] (Coronal, sagittal, transverse plane observations.)

Dynamic Assessment

• [Environment and challenge level] (Parallel bars vs open ambulation; level ground vs stairs/ramps; footwear.)
• [Tasks evaluated] (Sit-to-stand, transfers, standing balance, ambulation.)

(If gait or functional tasks not assessed, state: "Gait not assessed—[reason]" and omit above bullets.)

Skin Response After Trial

• [Approximate wear time during trial]
• [Post-doffing skin findings] (Locations of redness or pressure marks; note whether resolved during visit.)

Gait and Functional Observations

(Include this section only when ambulation or task performance was evaluated. If not assessed, omit section or state: "Gait evaluation not performed—[reason].")

• [Step length symmetry, cadence, base of support]
• [Toe clearance and foot placement]
• [Knee stability] (Buckling, hyperextension.)
• [Trunk lean and pelvic motion]
• [Device-specific deviations] (Vaulting, circumduction, hip hike, instability on uneven surfaces.)
• [Assistance level and supports used] (Guarding, parallel bars, handrails, assistive device.)
• [Adverse events or near-falls]
• [Standardized outcome measures] (Measure name, score, testing conditions. Omit if none performed.)

Alignment and Trimline Modifications

(Document all changes performed today. For each modification, include both the change and observed response.)

• Alignment changes: [Direction and magnitude] — [Observed response]
• Trimline adjustments: [Location and extent] — [Observed response]
• Relief and padding: [Location, type, rationale] — [Observed response]
• Straps/closures: [Adjustments, education on tightening sequence] — [Observed response]

(Include only modification types that apply; omit unused categories.)

Unresolved issues: [Persistent problems after in-session modifications] (Omit if all issues resolved.)

Clinical Impression

[Overall fit status and primary limiting factors] (3–6 sentences: whether fit is acceptable for continued trial or not acceptable; skin risk, volume mismatch, alignment instability, pain, device migration as applicable; appropriateness to proceed to next step—additional test fitting, fabrication modifications, or medical referral.)

Plan

Modifications Required:

• [Planned modification] — [Rationale]

(Add lines as needed; omit section if no modifications required.)

Follow-Up: [Appointment type and timeframe] (Next check fitting, delivery, follow-up.)

Patient Instructions: [Wear schedule, skin check instructions, stop rules for pain/blistering/persistent redness >20 minutes, safety precautions] (If no home wear prescribed, state: "No wear trial prescribed—device retained in clinic.")

Care Coordination: [Communication with referring clinician or therapy team] (Omit if none.)

Escalation Criteria: [When to contact O&P urgently vs seek medical care] (Open skin, infection signs, repeated falls.)

Device delivery status: Device not delivered today. (Change to "Device delivered" only if this was a delivery encounter.)