Orthotics & Prosthetics Initial Evaluation

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

Date: [Encounter date]

Location: [Clinic / Inpatient / Home]

Visit Type: Initial Evaluation

Clinician: [Clinician name], [Credentials], [NPI]

Referring Practitioner: [Referring practitioner name], [Contact information]

Primary Diagnosis: [Diagnosis with ICD-10 if available], [R / L / Bilateral], [Amputation level if applicable]

Payer: [Payer name], Authorization status: [pending / approved / not required / unknown]

Referral & Order Status

[Reason for referral in one sentence]

• Written order: [exists / pending / needed / not available at time of evaluation]
• Face-to-face encounter: [required / not required], [status and date if known]
• Prior authorization: [required / not required], [status and date if known]
• Coverage considerations: [Coverage uncertainties or special considerations, or "None identified"]

Chief Concern & Goals

Chief concern: [Patient's stated concern with brief quote if helpful]. [Clinician interpretation and context].

Functional goals:

• [Goal 1 as functional outcome with measurable criterion]
• [Goal 2 as functional outcome with measurable criterion]
• [Goal 3 as functional outcome with measurable criterion]

(Include 2–4 goals. If patient cannot articulate goals, document barriers and provide clinician-derived goals with rationale.)

History

[Onset and course: injury/surgery/amputation date, progressive vs stable]. [Current symptoms affecting device design: pain, skin issues, sensory changes, swelling, instability, falls, fatigue]. [Prior treatments or therapy and response].

• Prior device history: [Device type(s)], [Wear tolerance], [What worked/failed], [Current device issues if applicable]
• Prosthetics-specific: [Etiology of limb loss], [Healing status], [Revision history], [Volume management routine], [Current prosthesis: socket type, suspension, liner, foot/knee type, wear time] (Include only if applicable)
• Orthotics-specific: [Neurologic/orthopedic drivers: weakness, deformity, contracture, spasticity], [Footwear constraints], [Work/leisure demands] (Include only if applicable)
• Pertinent medical history: [Conditions affecting device selection, skin risk, training, or safety] (Omit unrelated history)
• Relevant allergies: [Interface material sensitivities: latex, silicone, adhesives, or "None reported"]

Functional Status

• Current mobility: [Nonambulatory / Household ambulator / Community ambulator / High-impact demands]; [Assistive devices used]
• Functional abilities: [Transfers], [Stairs], [Uneven terrain], [Driving], [Endurance/distances]
• ADL considerations: [Don/doff ability], [Skin check ability], [Other device-related limitations]
• Falls history (past 6–12 months): [Number of falls/near-falls], [Circumstances]
• Environment: [Home: steps, railings, surfaces], [Work/vocational demands] (Include only if relevant)

Prosthetics functional profile: [Current functional capability] vs [Expected functional potential]. [Justification if they differ]. (Support with concrete examples; do not overstate functional level without evidence.)

Physical Examination

(Document only elements actually examined. Do not imply normal for unexamined items. For telehealth encounters, note "Objective exam limited by encounter type.")

• General observation: [Cognition], [Safety awareness], [Ability to follow instructions]
• Anthropometrics: [Height], [Weight]
• Skin/soft tissue: [Integrity], [Redness], [Scars], [Wounds with location and size], [Tenderness]
• Edema/volume: [Presence], [Stability], [Character]
• Sensation: [Protective sensation], [Light touch], [Proprioception] (Specify locations and laterality)
• ROM/contractures: [Joint(s) assessed], [Limitations in degrees], [Contractures]
• Strength/motor control: [Key muscle groups with laterality and grade]
• Tone/spasticity: [Presence], [Pattern], [Severity] (Include if relevant)
• Alignment/deformity: [Varus/valgus], [Rotational issues], [Leg length discrepancy], [Fixed vs flexible]
• Gait observation: [Deviations], [Stability], [Foot clearance], [Knee control], [Compensations], [Assistive device use]
• Current device assessment: [Fit], [Suspension], [Wear patterns], [Component condition], [Sock ply], [Don/doff technique] (If applicable)
• Prosthetics-specific: [Residual limb shape], [Bony prominences], [Distal tolerance], [Flexion contractures], [Contralateral limb], [UE strength] (If applicable)
• Orthotics-specific: [Deformity flexibility: fixed vs correctable], [Joint instability with direction], [Footwear compatibility] (If applicable)

Outcome Measures

(Include only if standardized measures were performed; otherwise omit this section.)

• [Tool name]: [Score], [Interpretation]
• [Additional measure]: [Score], [Interpretation]

Assessment

[Synthesis of findings with problems listed in order of clinical severity/risk. Address rehabilitation potential and barriers.]

• Problem 1: [Description], [Supporting evidence], [Functional impact], [Device implications]
• Problem 2: [Description], [Supporting evidence], [Functional impact], [Device implications]

Expected functional potential: [Projection with justification based on objective findings] (Clearly label as projection; do not state unestablished diagnoses.)

Device Recommendation

Recommended device: [Orthosis/Prosthesis type] with [Key design features: stabilization planes, stance control, energy return, suspension, interface materials].

• Functional rationale: [How features address problems and support patient goals]
• Alternative considered: [Alternative device], [Reason not selected]
• Custom vs prefabricated: [Justification: multi-plane control, duration >6 months, tissue protection, unique morphology] (If custom)
• Component rationale: [Foot/knee/ankle category], [Functional requirements: variable cadence, terrain, stairs, safety] (Prosthetics only)
• Training needs: [Focus areas], [Responsible discipline: PT / OT / O&P]
• Risks and mitigation: [Skin breakdown / Fall risk / Cognitive limitations], [Mitigation plan]

Recommendation status: [Confirmed / Deferred pending: wound clearance, therapy evaluation, imaging, order clarification]

Measurement & Impression Plan

(Include when custom fabrication planned; document sizing method for off-the-shelf items.)

• Method: [3D scan / Plaster cast / Foam impression / Measurements only / Off-the-shelf sizing]
• Positioning: [Weight-bearing / Non-weight-bearing], [Limb angles]
• Key landmarks/measures: [Anatomical landmarks], [Circumferences], [Lengths]
• Volume management: [Shrinker use], [Sock ply], [Edema status]
• Tissue protection: [Wound/scar protection plan] (If applicable)
• Status: [Completed / Deferred: reason and when planned]

Plan

• Orders/authorization: [Order status], [Face-to-face documentation], [Prior authorization submission]
• Fabrication: [Test socket plan if prosthetics], [Components], [Expected turnaround], [Dependencies]
• Delivery plan: [Fit checks], [Education topics: don/doff, skin checks, wear schedule, maintenance]
• Training plan: [Responsible parties], [Focus areas], [Schedule]
• Follow-up: [Short-term: 1-2 weeks post-delivery], [Long-term reassessment for volume changes, growth, or disease progression]

Patient Education & Consent

• Education provided: [Topics covered], [Patient/caregiver understanding]
• Consent: [Consent for scanning/photography: obtained / not obtained], [Shared decision-making discussion]

Coordination

(Include if coordination occurred.)

• [Communication type: message, call, fax], [Recipient], [Purpose], [Date]
• [Dependencies on other providers: wound clearance thresholds, therapy milestones]

Signature

[Clinician signature], [Credentials], [Date/time signed]