Orthotics & Prosthetics Follow-Up/Adjustment Note

(Document what was observed and done with specific detail—avoid checkbox-only entries. Separate patient report from objective findings. Label clinical interpretations as "suspected" or "consistent with" when not definitively established. If information is unavailable, state explicitly rather than leaving blank. Omit sections that do not apply, but document the reason when core elements such as skin check or gait trial were not performed.)

Date/Time: [Encounter date and time]
Setting: [clinic / home / telehealth]
Provider: [Name, credentials, facility]
Patient: [Identifiers per policy]
Visit Type: [follow-up / adjustment / repair / training]
Device(s): [Device type, anatomic level, side, key components; custom vs prefabricated] (If device details are unavailable, state explicitly.)

Subjective

[Chief concern and timeline since delivery or last visit] (Use concise narrative; include direct patient quote if provided.)

[Wear adherence in days/week and hours/day; activities performed in device; adverse events such as falls, skin issues, or malfunction; relevant health changes affecting fit including weight change, edema, surgery, or volume fluctuation] (Include only details relevant to today's visit.)

Objective

Skin/Tissue: [Areas inspected and findings—redness, irritation, blisters, wounds—with location and characteristics] (If not assessed, state reason.)

Device & Fit: [Device condition and integrity; fit indicators including contact zones, pressure points, pistoning, alignment, suspension; for orthoses note trimlines and footwear compatibility; for prostheses note socket fit, liner condition, and component function] (Include measurements or settings if adjusted or verified.)

Function: [Gait and mobility observations if tested, including relevant deviations and assistive device use] (If not tested, document reason.)

Assessment

[Brief clinical summary linking the chief concern to objective findings] (Clearly differentiate observation from interpretation.)

[Problem list with suspected drivers—fit, alignment, limb volume change, user technique, component wear, or other—for each identified issue]

[Device use recommendation: continue as is / modify use parameters / hold use] (Specify conditions, limits, or prerequisites.)

Plan

Interventions performed: [For each adjustment or repair: indication, work performed with specific location and materials, patient response, and post-adjustment findings including skin and fit verification] (If repairs billed, document parts/labor justification and attest to continued medical need. If no interventions performed, explain why.)

Education provided: [Skin inspection guidance, updated wear/break-in schedule, device hygiene and care, when to stop use and contact clinic] (Include only topics addressed this visit.)

Follow-up: [Timeframe for next visit with return precautions for worsening skin, falls, or device failure; note any referrals to prescriber, PT/OT, wound care, or other services]

Signature: [Clinician name], [Credentials] — [Date/Time]