Orthotics & Prosthetics Repair/Replacement Procedure Note

Patient Name: [Patient full name]

DOB: [Date of birth]    MRN: [Medical record number]

Date of Service: [Date]    Time: [Start–End time]

Encounter Location: [Clinic / Hospital bedside / Home / Facility name and unit]

Rendering Clinician: [Clinician name, credentials]

Referring/Treating Practitioner: [Name, credentials] (Include only if applicable)

Service Summary

[Brief 2–4 line narrative capturing: service type (repair, replacement, repair with component replacement, or temporary safety intervention); primary reason for encounter; outcome (repaired and returned to service vs. removed from use with replacement initiated); and immediate safety disposition (safe to continue use vs. stop use with interim plan)]

Device Identification

(Repeat this subsection for each device addressed. If a field is pending, state what is being done to obtain it.)

• Device Type: [Orthosis or Prosthesis with specific type, e.g., AFO, KAFO, TLSO, transtibial prosthesis]
• Laterality: [Left / Right / Bilateral / N/A]
• Manufacturer/Model: [Manufacturer and model]
• Serial Number: [Serial number] (If unavailable, document reason or action to obtain.)
• Approximate Age/Original Delivery Date: [Device age or delivery date]
• Warranty Status: [In warranty / Out of warranty / Unknown]
• Key Components Relevant to Service: [Pertinent components: joints, uprights, liners, suspension, foot/knee unit, straps, closures, electronics]

Indication & Continued Medical Necessity

[Problem-focused narrative linking the device to the patient's condition, including: primary diagnosis or etiology requiring the device; deficits addressed (instability, weakness, limb loss, contracture management); current functional status summary (mobility level, ADLs impacted); and explicit statement of continued medical necessity]

(If replacement is being pursued, document the change prompting replacement and why replacement is required rather than repair. Reference treating practitioner documentation when required. Do not infer medical necessity conclusions.)

Subjective

[Patient/caregiver report including: reason for visit; onset and progression of the problem; symptoms and consequences (discomfort, skin issues, instability, falls or near-falls, reduced wear tolerance, ADL limitations); current usage pattern (hours/day, terrain, work demands); and interim measures attempted] (If a safety incident occurred, include a direct patient quote for key facts. If history is unavailable and no collateral source exists, document this limitation.)

Objective

(Document only findings assessed today. If a safety-critical element was not assessed, explicitly state the reason.)

• Patient Exam: (When interface contact is involved)
  • Skin Integrity: [Findings at contact points with location mapping] (If not assessed, state: "Skin check not performed—[reason]")
  • Edema/Volume: [Edema or volume changes]
  • Residual Limb: [Shape/volume changes] (Prosthetics only)
  • ROM/Strength: [Relevant findings]
  • Gait/Stance: [Observations with and without device if safe]
• Device Exam:
  • Structural Integrity: [Cracks, delamination, broken joints/struts, loose hardware, worn tread, corrosion]
  • Interface Wear: [Liners, padding, trimlines, strap elasticity, closure integrity]
  • Alignment/Fit: [Pistoning, gapping, pressure marks, migration, noise]
  • Safety Hazards: [Exposed sharp edges, unstable joints, lock failure, battery/charging faults]

Assessment & Failure Analysis

[Synthesis of findings including: problem statement at the component level; likely failure mechanism (wear, material fatigue, improper fit causing stress, accidental damage, patient condition change, maintenance lapse); safety risk level (low, moderate, high) with justification; and repairability determination (repairable now vs. requires replacement) including constraints such as parts availability or structural compromise]

Decision: Repair vs. Replacement

(Include only the applicable subsection. Ensure rationale is explicit and audit-ready.)

If Repair Selected:

• Goal of Repair: [Restore serviceability and safety]
• Medical Necessity Rationale: [Why repair is reasonable and necessary, tied to functional impact or safety risk]
• Scope Boundary: [Repair / Adjustment / Routine maintenance]
• Parts Replaced:
  • [Part/component name; quantity; OEM vs. equivalent; reason for replacement]
• Repair Labor Time: [HH:MM] (Hands-on repair only; excludes evaluation and education time)

If Replacement Selected:

• Replacement Target: [Entire device / Major component / Socket / Liner / Suspension / Module]
• Reason Category: [Change in patient physiological or functional condition / Irreparable change in device or part / Repair would not be durable or safe / Repair cost or extent makes replacement more appropriate]
• Objective Evidence: [Why repair is insufficient: repeated failure, structural compromise, unsafe performance]
• Continued Medical Necessity: [Explicit statement that device remains required for mobility or function] (Reference treating practitioner documentation when required.)
• Interim Risk Plan: [Stop-use instructions, temporary modifications, or alternate mobility plan] (If replacement is not same-day)

Procedure Details

• Preparation: [Cleaning, inspection steps]
• Repair Labor Time: [HH:MM] (Hands-on repair only)
• Work Performed:
  • [Sequential description: disassembly, repairs performed (bonding, rivet replacement, joint rebuild, shell repair, padding/strap replacement, alignment adjustment), programming/software updates for electronic devices, reassembly]
• Parts and Components Used:
  • [Part name; quantity; OEM vs. equivalent; lot/serial if available]
• Settings Changed: [Setting name: before → after values] (If applicable)
• Complications/Unexpected Findings: [Description and management] (If none, omit this line)
• Patient Tolerance: [Tolerated well / Issues encountered]

Post-Procedure Verification

• Fit/Suspension Check: [Findings]
• Structural Stability: [Findings]
• ROM/Joint Function: [Findings]
• Functional Demonstration: [Transfers, ambulation, stairs/ramps as appropriate]
• Post-Fit Skin Status: [Findings] (If interface contact; if not assessed, state reason)
• Outcome Statement: [Device restored to safe function / Device use restricted—specifics and any remaining limitations or planned additional work]

Patient Instructions

• [Updated wear schedule]
• [Donning/doffing reinforcement if needed]
• [Skin monitoring: what to look for and when to stop use]
• [Cleaning/maintenance patient can perform vs. requires clinician]
• [Charging/electronics instructions if applicable]
• [Activity restrictions and safety precautions]
• [What to do if symptoms recur or device fails again, with contact information]
• Understanding Confirmed: [Patient demonstrated... / Patient verbalized...] (Specify caregiver name if caregiver received education.)

Follow-Up Plan

• Follow-Up: [Timeframe and purpose]
• Triggers for Sooner Return: [Pain, persistent redness, falls, noises, loosening]
• Coordination Actions: [Treating practitioner contacted / New order requested / Prior authorization initiated / PT-OT referral / Wound care involvement] (If applicable)
• If Replacement Pending: [Next steps and requirements to proceed]

(Omit entire sections that do not apply. For safety-critical elements not assessed, explicitly document why. If required information is unavailable, document actions to obtain it. Use patient-specific details throughout.)