Wheelchair Seating & Mobility Evaluation Note

Date/Time: [Date and time of evaluation]

Place of Service: [clinic / home / inpatient rehab / SNF / hospital outpatient / other]

Evaluator: [Name], [Discipline: PT / OT], [Credentials including ATP/SMS if applicable]

Supplier/ATP Present: [Name], [Company], [Credential], [present in-person / present via video / consulted prior to visit] (Omit this line if no supplier/ATP involved)

Ordering Clinician: [Name], [Credentials], [NPI if available]

Patient Name: [Full name]

DOB: [Date of birth]

MRN: [Medical record number]

Height/Weight: [Height with units]; [Weight with units] (Note if self-reported)

Payer(s): [Primary payer and plan]; [Secondary payer if applicable]; [Prior authorization status if known]

Reason for Evaluation

[Concise 2–4 sentence narrative describing chief concern in patient-centered terms, what mobility/seating decisions this evaluation must support for DME coverage, whether this is an initial evaluation / replacement / modification / repair, referral source, and requested equipment category. Include information sources: patient report, caregiver report, chart review, referring clinician.]

Diagnoses and Relevant Medical History

• Primary diagnosis driving mobility limitation: [Diagnosis name]; [ICD-10 if known]
• Secondary conditions affecting seating/mobility: [Conditions such as spasticity, contractures, cardiopulmonary disease, obesity, amputation]
• Mobility-limiting symptoms: [weakness / pain / fatigue / dyspnea / ataxia / sensory loss / tremor / other]; [Functional impact]
• Relevant medications impacting function/safety: [Medications with functional implications: sedatives, antispasmodics, anticoagulants] (Omit if none relevant)
• Skin integrity: [Current pressure injury: location, stage, treatment]; [History of pressure injuries]; [Ability to perform independent weight shifts and frequency] (Include only if seating components are justified by skin risk)

Current Functional Status and MRADLs

• Ambulation status: [Distance tolerated], [assistive device used], [assistance level], [gait quality and safety]; [indoors vs outdoors]; [limitations and risks]
• Falls history: [Frequency], [circumstances], [injuries], [contributing factors]
• Transfers:
  • Bed: [technique: stand-pivot / sliding board / mechanical lift / other], [assistance level], [safety]
  • Toilet: [technique], [assistance], [DME used], [safety]
  • Shower/tub: [technique], [assistance], [DME used], [safety]
  • Car: [technique], [assistance], [safety]
• Current wheelchair use: [Type], [hours per day], [propulsion method], [endurance], [caregiver involvement], [fit/comfort issues] (Omit if no current wheelchair)
• In-home MRADL impact: (Describe task-specific barriers in customary home locations; document why current mobility is unsafe, inefficient, or not feasible, and what mobility support would enable completion. This section is coverage-critical.)
  • Toileting: [Current ability and barriers]; [Safety/efficiency concerns]; [Mobility support needed]
  • Bathing: [Current ability and barriers]; [Safety/efficiency concerns]; [Mobility support needed]
  • Dressing: [Current ability and barriers]; [Safety/efficiency concerns]; [Mobility support needed]
  • Grooming: [Current ability and barriers]; [Safety/efficiency concerns]; [Mobility support needed]
  • Feeding/meal access: [Access to kitchen/dining]; [Safety/efficiency concerns]; [Mobility support needed]
• Patient-stated goals: [Functional goals prioritized by the patient]
• Cognitive, visual, and perceptual status: [Judgment/safety awareness], [attention], [ability to learn and follow safety instructions], [vision and scanning], [UE control for drive interface] (Required if considering power mobility. If not assessed, state "not assessed" with reason.)

Home Environment

• Dwelling type and primary living level: [house / apartment / assisted living], [single-level / multi-level], [bedroom/bathroom level]
• Entry access: [stairs with number], [ramp], [elevator], [thresholds with heights]
• Bathroom setup: [tub/shower type], [toilet height], [grab bars / shower chair / commode]
• Flooring surfaces: [carpet / hardwood / tile / mixed], [threshold heights]
• Doorway widths and turning clearances: [Measured values] or [Patient report]; [tight areas of concern]
• Caregiver availability/capability: [Availability], [willingness], [physical capability for propulsion/transfers]
• Transportation and storage: [Vehicle access and loading], [charging location], [indoor storage constraints]
• Home Assessment Status: [completed today / to be completed by supplier / pending scheduling] (If not completed, document plan for obtaining missing measurements)

Clinical Examination

• Anthropometrics: [Height], [Weight]
• Strength and ROM: [UE strength and ROM], [LE strength and ROM], [trunk control]; [fixed vs flexible contractures impacting seating angles]
• Tone and movement disorders: [spasticity / clonus / dystonia / tremor], [distribution and functional impact]
• Sensation (buttocks/ischial regions): [intact / diminished / absent] (Include when cushion justification depends on this finding)
• Sitting balance and head control: [static balance], [dynamic balance], [need for external support], [head control]
• Cardiopulmonary endurance: [dyspnea/fatigue with mobility tasks], [vital response if measured]
• Skin inspection: [areas of redness], [non-blanching erythema], [moisture], [shear risk during transfers]
• Functional mobility tests: [Test name and result: TUG, gait speed, wheelchair propulsion trial] (If not performed, state reason)

Seating Evaluation

• Current seating system: [Make/model], [dimensions], [cushion/back type], [fit issues: width mismatch, sling seat hammocking, inadequate support], [equipment condition and safety] (Omit if no current seating system)
• Mat evaluation:
  • Pelvis: [obliquity], [rotation], [posterior/anterior tilt], [flexibility]
  • Trunk: [scoliosis], [kyphosis], [flexibility]
  • Hip/knee/ankle ROM for seating angles: [available ranges], [limitations affecting seat-to-back angle, legrest angle]
  • Supports needed: [type and location of supports required for midline or functional improvement]
• Pressure management assessment: [ability to perform pressure relief], [need for skin protection vs positioning vs combination]; [pressure mapping results and clinical interpretation if performed]
• Upper extremity function for mobility: [manual propulsion feasibility: strength, endurance, shoulder pain, coordination], [ability to manage wheelchair components], [joystick reach/control quality or need for alternative access]

Measurements

(Provide seated measurements in consistent units. If measurements are not taken today, specify who will obtain them.)

• Hip width: [value]
• Thigh length (seat depth): [left], [right]
• Lower leg length (seat-to-floor): [left], [right] (include shoe thickness if relevant)
• Seat-to-shoulder: [value]
• Seat-to-scapula: [value]
• Seat-to-top-of-head: [value] (Include if head support considered)
• Environmental: [Narrowest doorway width], [turning space], [bed height], [toilet height], [threshold heights] (Indicate if measured vs patient-reported)
• Measurements pending: [Items], [Responsible party: clinic follow-up / supplier home visit], [Timeline]

Equipment Trials

(Document each device/component trialed. Repeat the block below for each trial.)

• Device/Component Tested: [mobility base / cushion / back / lateral supports / power seating function / drive control]
• Setup/Configuration: [Dimensions, adjustments, programming relevant to trial]
• Patient Performance Observed: [propulsion/operation ability], [task completion], [maneuverability], [fatigue/pain response], [skin response]
• Safety Findings: [stability], [transfer safety], [postural control], [environmental clearance]
• Patient Preference/Feedback: [comfort], [usability], [acceptance]
• Objective Outcomes: [Timed or measurable outcomes relevant to MRADLs if obtained]
• Conclusion: [accepted / rejected]; [clinical rationale]

Mobility Option Rationale

(Provide payer-facing medical necessity reasoning. Include only sections relevant to the recommended option.)

• In-home MRADLs impaired and mechanism: [Tasks affected], [Why impaired: falls risk / inability to complete / unreasonable time / morbidity risk]
• Why cane or walker is insufficient: [safety / endurance / pain / strength / balance / neurologic factors with specifics]
• If recommending manual wheelchair: [How it will improve MRADLs and be used regularly in home], [self-propulsion ability or caregiver availability], [why selected base level is required: standard vs lightweight vs ultralight vs custom]
• If recommending scooter/POV: [safe transfer ability], [ability to operate tiller steering], [postural stability while operating], [home maneuverability]
• If recommending power wheelchair: [why optimally-configured manual wheelchair is not feasible], [why POV is inappropriate], [ability to operate safely], [home maneuverability: turning radius, thresholds, surfaces], [weight capacity class if relevant]
• Justification for power options/accessories: (Include only those recommended)
  • Tilt: [angles required], [purpose: pressure relief / postural stability / tone management / pain management]
  • Recline: [medical purpose: catheterization / hygiene / orthostasis / edema management]
  • Elevating legrests: [medical purpose: edema / ROM limitations / pain]
  • Seat elevation: [specific in-home tasks requiring it: transfers / cabinet access / pressure management during reach]
  • Alternative drive controls: [why standard joystick is not feasible], [how selected interface enables safe control]

Recommended Equipment

Wheelchair Base

• Category: [manual / power / POV]; [HCPCS code category if applicable]
• Make/Model: [Specific model or "comparable medically necessary equivalent"]
• Seat dimensions: [width x depth]
• Frame configuration: [folding / rigid / mid-wheel / front-wheel / rear-wheel]; [other key features]

Seating System

• Seat cushion: [category: skin protection / positioning / combination], [properties], [custom fabrication if applicable]
• Back support: [category], [contour depth], [height]
• Positioning components: [pelvic belt], [lateral trunk supports], [medial thigh support], [head support], [arm supports] (Include only those recommended)
• Foot/leg support: [swing-away / elevating / center-mount], [angle], [calf pads / heel loops]

Drive Controls and Electronics

(Include for power mobility only)

• Primary drive control: [joystick type / alternative interface], [mounting], [positioning]
• Controller/programming needs: [controller type], [profile settings], [specialty modules]

Power Seating Functions

(Include only those recommended)

• Tilt: [angle range], [functional purpose]
• Recline: [angle range], [medical purpose]
• Elevating legrests: [range], [purpose]
• Seat elevation: [range], [specific in-home tasks enabled]

Safety and Transport

• Safety features: [anti-tippers], [stability options]
• Transit/transport: [transit tie-downs if needed], [charging location]

Replacement Justification

(Include only for replacement evaluations)

• [Why current equipment no longer meets needs], [why modification is insufficient], [age/condition of current device], [changes in medical status]

Medical Necessity Summary

(Concise 1–2 paragraph payer-facing summary suitable for Letter of Medical Necessity)

[Summarize diagnoses and key impairments, specific in-home MRADL limitations, why lesser mobility options are insufficient, why selected base and key seating features are required, confirmation of home feasibility and safe operation, expected daily use in home, and duration of need.]

Plan and Follow-up

• Supplier coordination: [quotes requested/received], [prior authorization requirements], [home assessment scheduling]
• Treating practitioner orders: [orders needed and status]
• Delivery and fitting plan: [anticipated timeline], [location], [participants]
• Training plan: [driving training], [pressure relief program], [caregiver training], [equipment management]
• Follow-up schedule: [post-delivery fit check], [skin check], [re-evaluation triggers]
• Contingency if authorization denied: [appeal plan / alternate equipment plan / additional documentation required]

Signature

Evaluator Signature: [Name], [Credentials], [Date]

Attachments: [photos / pressure mapping summary / measurement sheets / trial documentation / other]