Orthotics, Bracing, or Taping Note

(Document only what occurred during this encounter. Tailor each section to the selected encounter type.)

Patient: [Patient name and identifiers per organization policy]

Date/Time: [Date and time of service]

Setting: [clinic / inpatient / training room / home visit / other]

Author: [Name, credentials, role]

Encounter Type: [evaluation/selection only / fitting/delivery / follow-up/adjustment / taping/strapping application]

Referral Source: [Referring provider and order date] (Include only if applicable; omit if self-referred or no external order exists.)

Indication

[Body region with laterality, primary functional problem, and time course] (One to two sentences. Example: Right knee brace evaluation for recurrent medial instability during ambulation, 6 weeks post-MCL grade II sprain.)

History

[Relevant condition history, patient goals and preferences, prior device experience, and pertinent comorbidities] (Include injury mechanism and timing; surgical details and protocols if post-op; patient goals such as comfort, ease of donning, return-to-activity timeline; prior orthotic/bracing/taping experience and response; comorbidities affecting selection such as peripheral neuropathy, vascular disease, diabetes, fragile skin, cognitive impairment, fluctuating edema; for taping, note adhesive allergies or skin sensitivities; current skin integrity at proposed application sites. If patient goals were not elicited, briefly state why.)

Examination

(Focused objective findings pertinent to the device indication.)

• [Inspection findings] (Swelling, deformity, alignment, surgical incisions as relevant.)
• [Pre-application skin assessment at contact zones: intact / erythema / open areas / fragile areas] (Specify locations.)
• [Neurovascular screen: intact / diminished / absent] (Sensation, distal pulses or capillary refill, temperature with location.)
• [Range of motion relevant to device indication] (Include degrees; note protocol restrictions for post-op patients.)
• [Strength relevant to device indication] (Include grading or functional description.)
• [Stability testing] (For instability indications: document the specific test performed and objective finding with measured laxity if available. Subjective instability reports alone are insufficient.)
• [Functional observations] (Gait quality, transfers, sport-specific movements as applicable.)
• [Measurements if sizing/fitting performed] (Circumferences at defined landmarks, length measurements, shoe size. For hinged braces, include ROM settings and strap placement. If no fitting performed, state explicitly.)

Assessment

[Clinical summary linking findings to the need for orthotic/brace/taping intervention] (Synthesize how history and examination support medical necessity. Note contraindications or precautions identified such as open wounds at contact points, adhesive allergy, significant edema fluctuation. Do not infer objective findings not directly observed or tested.)

Device or Taping Details

• [Body region and laterality]
• [Device category or taping modality] (Hinged knee orthosis, lumbosacral orthosis, ankle-foot orthosis, rigid athletic tape, kinesiology tape, etc.)
• [Manufacturer/model and size] (If applicable.)
• [Key components and settings] (ROM limits, varus/valgus adjustments, hinge type, strap configuration, tension settings as relevant.)
• [Selection rationale] (Intended biomechanical effect—stabilization, unloading, ROM restriction, proprioceptive input—and why chosen over alternatives.)
• [Fitting, modification, or application details] (Preparation including positioning and skin prep; device modifications such as trim line adjustments, heat molding, strap relocation, padding additions with rationale; for taping, describe technique including anchor points, direction of pull, and layers.)
• (If evaluation-only encounter, explicitly state that no device or tape was applied.)

Post-Application Check

(Include only when a device or tape was applied during this encounter; otherwise omit entire section.)

• [Fit verification] (Alignment, suspension, absence of gapping or pressure points.)
• [Immediate skin status] (Skin appearance after application; note any irritation with location and response.)
• [Post-application neurovascular status: unchanged / improved / concerns noted]
• [Functional trial] (Gait or task performance, stability changes, pain response.)
• [Patient tolerance and confidence with device]

Patient Education

• [Donning/doffing technique or tape removal instructions]
• [Wear schedule] (Break-in period if applicable; activity-based parameters; continuous wear per protocol if indicated.)
• [Patient-adjustable components vs. those requiring clinician adjustment]
• [Skin check instructions] (Frequency; signs to monitor such as persistent redness >20–30 minutes after removal, blistering, numbness, increased swelling; when to contact clinic or seek urgent care.)
• [Device maintenance/cleaning or post-tape skin care]
• [Teach-back: completed / deferred] (If deferred, state reason and plan to complete. If completed, note comprehension and areas needing reinforcement.)

Plan

• [Follow-up timeline and objectives] (What will be reassessed: fit, skin tolerance, ROM progression, functional progress, adherence.)
• [Anticipated modifications at follow-up] (If applicable.)
• [Return precautions] (Skin breakdown, persistent numbness or tingling, increasing swelling, worsening pain, signs of infection.)
• [Provider coordination] (Communication to referring clinician, ongoing therapy plan, imaging or surgical follow-up as applicable.)