Prosthetic Component Change/Upgrade Evaluation Note

Date/Time: [Date and time of encounter]

Provider: [Provider name and credentials] ([prosthetist / physical therapist / occupational therapist / physician / APP])

Patient: [Patient name and identifier per local policy]

Limb: [right / left / bilateral] [amputation level]

Encounter Type: [evaluation for authorization / implementation visit / combined]

Evaluation Summary

Patient evaluated for component change from [current component(s)] to [requested component(s)] due to [primary reason].

Current prosthesis: [Brief description of socket/interface, suspension, knee if applicable, and foot/ankle]

Requested change(s): [Each requested component with functional intent in clinical terms]

Functional classification: [K0 / K1 / K2 / K3 / K4] — [One-line basis citing observable anchors such as community ambulation, stair/ramp negotiation, cadence variability, or environmental demands] (If expected functional potential differs from current demonstrated level, state expected level and briefly explain why current performance is below potential.)

History and Functional Status

Prosthetic history: [Time with current setup; prior components trialed; what worked or failed]

Relevant medical conditions: [Conditions affecting prosthetic function and safety] (Only include conditions relevant to prosthetic use.)

Current function: [Daily wear time; mobility for transfers and ambulation; stair/ramp/uneven terrain ability; community and vocational activities as relevant]

Functional barriers linked to current componentry: [Statements directly connecting limitations to component deficiencies] (Example: "Unable to safely descend slopes due to delayed stance control.")

Falls/safety history: [Falls or near-falls with circumstances, or state "Denies falls"] (Include if safety concerns are part of justification.)

Patient goals: [Functional goals in measurable terms]

Objective Assessment

Residual limb/skin: [Integrity, pressure areas, volume changes, interface tolerance; any breakdown with location and severity] (If skin issues drive request, link to interface/component.)

Prosthesis inspection: [Component condition/wear; socket fit; suspension integrity; liner condition; stance stability and swing clearance]

Gait/functional observations: [Cadence, symmetry, stance stability, turning, performance on challenging surfaces; assistive device use]

Outcome measures: [Test name, date, score, and interpretation for each measure performed] (If none performed, state "None performed" with reason and plan for future assessment.)

Medical Necessity Justification

(For each requested component, document the following elements.)

Requested component: [Component type with key functional features described clinically]

Current component insufficient because: [Link to specific objective findings and functional limitations documented above]

Expected improvements: [Health outcomes such as fall risk reduction, energy expenditure, injury prevention] and [specific ADL/community/vocational gains]

Lower-level alternatives considered: [Alternatives and why each does not meet this patient's functional demands]

Safe use capacity: [Patient's ability to manage charging, alerts, and mode switching] (Include only for advanced technology with user-management requirements.)

Replacement reason: [physiologic change / irreparable damage / repair cost threshold / functional need change] with supporting evidence (Include only when replacing a major component.)

Plan

Components to order/install: [Components and key specifications]

Fitting/alignment plan: [Socket modifications, suspension adjustments, alignment steps] (Include if major changes planned.)

Therapy plan: [PT/OT referral with targeted skills if indicated]

Follow-up: [Timeline for fittings/checks; outcome measures to reassess]

Work completed today: [Components installed; post-change functional and skin check; activity restrictions] (Include only if components installed this visit.)

(For any required element where information is unavailable, state "Not assessed," "Unknown," or "Deferred" with brief reason and plan to obtain.)