Prosthetic Check Socket Test-Fit Note

Date: [Date]

Clinician: [Name, credentials]

Side/Level: [e.g., Right Transtibial]

Test Socket #: [Number in current prosthesis series]

Subjective

[Reason for visit and goals for today's session]

• [Comfort and pain report: anatomical location, severity, timing]
• [Skin tolerance since last visit]
• [Volume fluctuation and sock ply management]
• [Falls, near-falls, or stability concerns]
• [Current mobility context and assistive device use]
• [Patient priorities for this session]

(Include only items explicitly discussed; omit items not addressed.)

Objective

Residual limb status: [Skin inspection findings with anatomical location, volume assessment, ROM/strength observations relevant to alignment]

Device configuration: [Socket design/type, interface (liner type/size, sock ply), suspension method, foot/knee components, footwear worn]

Static fit: [Donning ease, trimline appropriateness, total contact quality by region, suspension integrity, standing alignment]

Dynamic trials:

• [Testing conditions: surface, assistive device, duration/distance]
• Alignment adjustments: (Repeat the following block for each meaningful adjustment in sequence.)
  • [Observation or patient report prompting change]
  • [Adjustment made: component, plane, direction, magnitude if known]
  • [Immediate result: symptom change, pressure distribution, gait improvement]
• Gait observations: [Deviations by phase and side]
• Pressure areas: [Anatomical location, severity, resolution timing after doffing, patient sensation, action taken] (Repeat for each distinct area.)

Dynamic trials deferred: [Reason] (Include only if trials were not performed; otherwise omit this line.)

Assessment

[Overall fit quality: contact, suspension, comfort] [Overall function: stability, gait quality, assistance level] [Primary limiting factors] [Readiness for definitive fabrication, or rationale for continued test fitting linked to observed findings]

(Provide concise synthesis; explicitly state readiness vs. need for further testing.)

Plan

Modifications: [Planned socket, interface, or alignment changes] (Omit if none.)

Follow-up: [Timing, evaluation focus, definitive fabrication timeline if applicable]

Patient Instructions: [Wear time limits, skin check guidance, sock management, return precautions] (Include only instructions provided.)

Coordination: [PT/OT or physician follow-up needs] (Omit if none.)