Orthotics & Prosthetics Measurement/Casting/3D Scan Procedure Note

Date/Time: [Date and time of capture]

Location/Setting: [Clinic / hospital unit / bedside / home / other]

Clinician: [Name, credentials, role]

Patient Identifiers: [Identifiers per organizational policy]

Order/Prescription Reference: [Order ID, prescriber, date] (If unavailable, document: "Order not available at time of capture—requested from prescriber.")

Work Order/Lab Ticket Number: [Number] (Include only if applicable)

Procedure Summary

Procedure: [Body region with laterality] — [capture method(s): measurements / cast / impression / foam box / 3D scan / photos / tracings] for [purpose: initial fabrication / remake / replacement / modification / volume-change follow-up]. (Single structured line. If laterality or other clinically required information is missing, flag as "Clarification required: [item]" rather than inferring.)

Clinical Context

[Brief context (2–4 sentences) describing current device status (new vs replacement and reason), relevant interval changes since last O&P visit (weight, edema/volume, wounds, pain, functional status), and any constraints affecting capture (contracture, positioning tolerance, spasticity, fragile skin).] (If a same-day comprehensive evaluation note exists, reference it rather than repeating details.)

Pre-Capture Limb/Segment Status

(Document objective findings of the limb or body segment at time of capture. Specify laterality. Do not infer skin status under dressings or liners not removed. Omit items that do not apply rather than inserting placeholders.)

• Skin integrity: [Findings with locations and sizes of any wounds, abrasions, blistering, maceration, dermatitis, scars, grafts, or adherent tissue]
• Edema: [Distribution and severity: none / mild / moderate / severe; pitting grade if applicable]
• Pain/tenderness: [Locations and severity to palpation]
• Bony prominences: [Areas requiring attention]
• Residual limb characteristics: [Distal end condition; limb shape; redundant tissue or invaginations] (Include only for residual limb captures)
• Unable to assess: [Area]: [Reason] (Include only for clinically important areas not examined)

Positioning and Loading Conditions

(Required for all casts and 3D scans. Include for measurement-only encounters if positioning/loading materially affects shape.)

• Patient position: [seated / supine / prone / standing]
• Joint angles/posture: [Knee flexion, ankle position, elbow flexion, spinal posture as applicable with degrees]
• Weight-bearing status: [non-weight-bearing / partial weight-bearing / full weight-bearing] — [load distribution description if applicable]
• Interface worn during capture: [liner type and thickness / sock ply / shrinker / footwear / bare skin]
• Landmark marking method: [skin marker / tape / none]
• Deviations from standard positioning: [Describe deviation due to patient factors and compensation method] (Omit if standard positioning achieved)

Capture Details

(Include only subsections for capture methods actually performed. If multiple body segments were captured, repeat the relevant subsections for each segment with clear segment identification.)

Manual Measurements

• Reference point/zero: [Defined origin, e.g., "0 cm at medial tibial plateau"]
• Circumferences (cm): [Values at standardized intervals from reference point]
• Lengths and dimensions (cm): [Overall limb length; AP/ML dimensions; heel-to-knee; foot length/width; other relevant measures]
• Measured over: [liner / stockinette / bare skin] with [thickness/ply if applicable]

Casting/Impression

• Materials: [plaster / fiberglass / alginate / foam box / other]
• Skin protection: [stockinette / plastic wrap / barrier / none]
• Key molding maneuvers: [Targeted contouring, pressure, and shaping techniques applied]
• Cast integrity upon removal: [intact / defects noted: describe]
• Patient tolerance: [well tolerated / issues: describe]

3D Scanning

• Scanner/software: [Device model; software version if available]
• Scan boundaries: [Proximal and distal extents]
• Landmarks: [marked on skin and visible in scan / added digitally post-capture]
• Scan quality: [complete / motion artifacts / repeats required]
• File information: [File type, naming convention, storage location or system reference]

Photos/Tracings

• Views captured: [List views]
• Scale marker: [used / not used]

Key Landmarks Identified

(List landmarks relevant to the captured region with identification method. For landmarks not reliably identified, note why.)

• [Landmark name] — [palpated / marked on skin / visible reference / estimated]
• [Additional landmarks as applicable]

Rectification and Design Intent

(Link each planned modification to its clinical rationale. Quantify adjustments when feasible.)

• Relief areas: [Specific regions] — [Reason: bony prominence / scar / wound / sensitive area]
• Loading/build-up zones: [Pressure-tolerant areas] — [Rationale]
• Trimlines and contours: [Intended trimlines with landmark references]
• Volume adjustments: [Magnitude and location of reductions or additions]
• Alignment intent: [ML/AP considerations; bench alignment assumptions]
• Interface assumptions: [Liner thickness; sock ply; padding assumptions]

Fabrication Instructions

(Include only if fabrication parameters are determined at time of capture; omit entire section if deferred to later encounter.)

• Device type/configuration: [Description]
• Materials and thickness: [Specifications]
• Interface specifications: [Liner, pads, straps, closures]
• Trimline specifications: [Referenced to anatomical landmarks]
• Hardware/components: [List]
• Cosmesis/finish: [Color, cover, finish]

(For undecided parameters, note: "To be finalized at test fitting.")

Post-Capture Findings

• Patient tolerance: [well tolerated / issues: describe]
• Post-capture skin status: [Findings for areas contacted by casting/scanning materials] (Do not assume normal if not examined)
• Adverse events: [none / describe event and actions taken]

Follow-Up Plan

• Next step: [test fitting / dynamic alignment / delivery / other] in [timeframe]
• Coordination: [Communication with prescriber, PT/OT, obtain shoes, scheduling, authorization as applicable]
• Activity restrictions: [Specify only if indicated; otherwise omit]