Wheelchair Seating & Mobility Evaluation Report

(Global meta-instructions: If information for a section was not obtained during the encounter, omit that section or write "Not assessed" with a brief reason. For payer-facing reports, explicitly address MRADLs in the home, skin risk criteria, and progression from simpler to more complex device alternatives. Do not infer payer, supplier, ordering practitioner, equipment brand/model, or skin risk qualifying criteria from diagnosis alone. Use measured values where available and label patient-reported values as "stated." Keep the Executive Summary readable as a standalone section.)

Date: [Evaluation date]

Patient Name: [Full name]

DOB: [Date of birth]

MRN: [Medical record number]

Height: [Value and units] [measured / stated]

Weight: [Value and units] [measured / stated]

Evaluation Type: [initial / replacement / repair or modification / reevaluation due to change in condition]

Evaluating Clinician: [Name, credentials, organization, contact information]

Referring Practitioner: [Name, role]

Reason for Referral: [Brief statement of mobility limitation, posture concern, skin protection need, and/or participation barrier prompting referral]

Primary Diagnoses: [Medical diagnoses relevant to mobility and seating needs]

Executive Summary

[Diagnosis-driven impairments and functional consequences; why wheelchair/seating intervention is needed now] (2–4 concise sentences linking primary conditions to current safety, MRADL, posture, or skin protection needs.)

[Current equipment problem statement if applicable] (State what is unsafe or insufficient: transfers, MRADLs in the home, pressure injury risk, postural concerns.)

Bottom-line Recommendation: [Recommended category, e.g., ultralight manual wheelchair, complex rehab power wheelchair] with [top 2–3 medically necessary features]

Expected Functional Outcomes:

• [Measurable expected outcome 1 tied to mobility, posture, or skin protection]
• [Measurable expected outcome 2]
• [Measurable expected outcome 3]

(Include 3–5 measurable outcomes total.)

Medical and Functional History

Diagnoses and Clinical Course

[Primary diagnoses with onset and severity; prognosis as it relates to mobility needs: stable / progressive / expected decline; relevant surgical history; active precautions such as weight-bearing restrictions, hip precautions, skin fragility, orthostatic intolerance, fracture risk]

Skin Integrity

[Current skin status: intact or describe open areas with location and stage if qualified to stage; pressure injury history with locations and dates if known; scarring or recurrent redness; sensation status in seated weight-bearing areas: intact / impaired / absent; ability to perform independent pressure relief or weight shift]

Functional Baseline

[Current mobility status: ambulatory household or community / wheelchair user / mixed; transfer method and assistance level; sitting tolerance and pain profile; upper and lower extremity limitations affecting propulsion or device operation including strength, ROM, coordination, and endurance; relevant cognitive, visual, or perceptual factors impacting safety and device use]

Current Equipment

[Current mobility base and seating system description: make and model if known, age, condition, fit issues, weight capacity; current cushion and back, positioning components, power functions if applicable, and drive controls. Document what is failing or unsafe AND what is working well. If details unknown, describe observable features and problems without guessing brand or model.]

Patient Goals and Problem List

Patient-Stated Goals

• "[Direct patient quote that illuminates priorities]" — [Clinical translation of goal]
• (Add additional goals as stated.)

Prioritized Problem List

(List identified problems in order of clinical risk. Not all categories will apply to every patient.)

1. [Problem description] (Categories in priority order: skin breakdown risk or current wound; falls or safety risk; postural deformity progression risk; functional MRADL limitations in home; pain, fatigue, or overuse injury risk; community access barriers.)
2. [Additional problems as applicable]

Functional Mobility Goals

• [Measurable, environment-specific goal tied to MRADLs with timeframe, e.g., "Independent toilet access within home bathroom with 28-inch doorway within 4 weeks of delivery"]
• [Additional measurable goals as applicable]

Objective Evaluation

Observation in Current Wheelchair

• Posture: [Pelvis: tilt, obliquity, rotation; Trunk: scoliosis, kyphosis, lordosis; Head and neck alignment; Lower extremity position] (Document as-is; note separately if temporary supports were trialed.)
• Stability and Midline: [Ability to maintain midline; fatigue over time]
• Skin Risk Observations: [Redness, high-pressure points, shear indicators after sitting or tasks]
• Functional Performance: [Reach; propulsion or drive; braking; transfers; pressure relief technique]

Mat Assessment

• ROM and Flexibility: [Hip flexion, hamstring length, pelvic mobility, knee flexion limits, ankle ROM] (Note values relevant to seating angles.)
• Tone and Spasticity: [Patterns and severity]
• Skeletal Deformities: [Description] — [flexible and correctable / fixed and to be accommodated]
• Trunk Control: [Performance in unsupported sitting]

Strength and Motor Control

• [Upper extremity strength and endurance for manual propulsion and pressure relief]
• [Hand function for joystick, switches, brakes, wheel locks]
• [Respiratory endurance if relevant]

Sensation and Skin Inspection

• Sensory Status: [Findings in buttocks, ischial, sacral, and posterior thigh regions]
• Pain: [Location and intensity; whether sitting exacerbates pain]
• Skin Inspection: [Findings] (If inspection was limited or refused, note reason.)

Anthropometric Measurements

• Hip Width: [Value and units]
• Seat Depth (buttock to popliteal): [Value and units]
• Lower Leg Length: [Value and units]
• Shoulder Height: [Value and units]
• Elbow Height: [Value and units]
• Thigh Clearance: [Value and units]
• Chest Width: [Value and units]
• Head Support Height: [Value and units] (If applicable.)
• Weight Distribution Considerations: [Notes affecting base selection]

(Document measurement method, clothing and footwear status, and laterality where relevant.)

Functional Mobility Task Performance

• MRADLs in Home: [Toileting access; bathing access; kitchen tasks; bed mobility interface] (Note if simulated rather than in actual home.)
• Transfers: [Surfaces; heights; assistance level; how wheelchair features affect safety including armrest style, seat height, footplate swing-away]
• Ambulation Status: [If patient ambulates, explain why gait device is insufficient and how wheelchair will be used: full-time / part-time]

Environmental Assessment

• Home Layout: [Doorway widths, turning radius constraints, flooring, thresholds and ramps, bathroom configuration]
• Transportation: [Method and vehicle stowage needs]
• Information Source: [home visit / patient report / caregiver report] — [Confidence level]
• Community Environment: [Terrain, distance, work or school requirements] (Document separately from in-home needs.)

Equipment Trials and Alternatives Considered

Alternative Device Categories

(Document progression from simpler to more complex technology. Include only categories considered for this patient.)

• [Device category considered]: [Reason this alternative fails to meet needs or is contraindicated]
• (Typical categories: cane or walker, standard manual wheelchair, ultralight manual wheelchair, power assist add-on, scooter or POV, standard power wheelchair, complex rehab power wheelchair.)

Equipment Trials Performed

• Trial Configuration: [Base type and key features; seat dimensions; cushion type; back height; tilt and recline angles; controls tested]
• Tasks Tested: [Propulsion or drive; turning; transfers; pressure relief; reaching; ramps and thresholds]
• Outcomes: [Objective measures such as distance, time, assistance level; subjective measures such as comfort, pain, perceived safety]
• Adverse Events: [Instability; skin redness; autonomic symptoms; other safety events]

(Repeat for additional trials. If trials could not be performed, document reason and substitutes used such as simulation or prior documentation.)

Assessment and Clinical Reasoning

Impairment-Risk-Function Summary

[Link postural findings to skin and shear risk and functional impact including reach, propulsion, swallow, and vision. Link upper extremity limitations to power mobility need. Link cognitive and visual findings to control interface selection.]

Required Documentation Statements

(These statements must be explicitly documented; do not leave blank or infer from diagnosis.)

• Pressure Injury: [present / history of / none] — [Location, stage, and dates if applicable]
• Sensation Impairment: [intact / impaired / absent in seated weight-bearing areas] — [Description]
• Functional Weight Shift: [able / unable to perform independently] — [Method and frequency if able]
• Postural Asymmetries: [present / none significant] — [Description and whether flexible or fixed]
• Safety to Operate Device: [Patient demonstrates capacity / Requires caregiver operation] — [Attendant control plan if applicable]

Medically Necessary vs Preference Features

• Medically Necessary: [Features required for safe MRADLs, posture management, skin protection, or transfers with rationale for each]
• Preference or Comfort: [Features that are not medically required] (Clarify these are preference-based.)

Recommendations

Mobility Base

Recommended Category: [manual / ultralight / heavy-duty / power assist / POV / power wheelchair / complex rehab power wheelchair]

• Key Specifications: [Seat width] x [Seat depth]; [Frame type]; [Seat-to-floor height]; [Weight capacity]
• Medical Necessity Narrative: [Explain how this base resolves the mobility limitation in the required environment and why lesser alternatives do not meet needs, referencing MRADLs in the home.]

Seating System

Seat Cushion: [general use / positioning / skin protection / combination / custom fabricated] — [Rationale tied explicitly to skin risk criteria and/or postural asymmetries]

Back Support: [general use / positioning / custom] — [Rationale tied to postural support needs]

Secondary Supports

(Include only components recommended for this patient. Document intent explicitly as postural support.)

• [Component name]: [Clinical problem addressed]; [Functional benefit]; [Safety considerations including quick-release and training needs]

Lower Extremity Support

• [Footplates / Elevating leg rests / Calf panels]: [Indication such as edema management, knee ROM limits, positioning needs, transfer mechanics]

Power Seating Functions

(Include only if power seating is recommended.)

• Tilt: [Indication tied to objective findings such as pressure management due to inability to weight shift, tone management, positioning]; [Contraindications or precautions]; [Training requirements]
• Recline: [Indication]; [Contraindications or precautions]; [Training requirements]
• Elevating Leg Rests: [Indication]; [Training requirements]
• Seat Elevation: [Indication such as transfer mechanics, reaching for MRADLs, vision and communication]; [Training requirements]

Drive Controls

(Include only if power mobility is recommended.)

• Primary Control: [joystick / head array / sip-and-puff / switch scanning / other] — [Rationale based on upper extremity function, ROM, tone, endurance, cognition]
• Attendant Control: [required / not required] — [Rationale and use plan if required]

Items Considered but Not Recommended

• [Alternative item] — [Brief reason for rejection]

Final Specifications

Configuration Summary

(If final make and model not yet selected, document required functional specifications.)

• Base: [Category]; [Key functional specifications]; [Compatibility notes]
• Cushion: [Type]; [Size]; [Key characteristics]
• Back Support: [Type]; [Height and contour]; [Size]
• Secondary Supports and Accessories: [List each with sizes and mounting details]

Power Settings

(Include only if power mobility is recommended.)

• Drive Profile: [Speed limit]; [Acceleration]; [Turning sensitivity]
• Seating Function Ranges: [Tilt degrees]; [Recline degrees]; [Seat elevation range]; [Elevating leg rest range]

Safety and Risk Mitigation

• Stability Features: [Anti-tippers or other features with indication]
• Pressure Relief Schedule: [Frequency and method; caregiver role if applicable]
• Skin Check Schedule: [Frequency and who will perform]
• Transfer and Falls Plan: [Risk level and caregiver assistance needs]

Training and Follow-up Plan

Training Plan

• Operation and Safety: [Brakes; ramps; hazard negotiation]
• Pressure Management: [Weight shift schedule; tilt and recline use; skin inspection routine]
• Transfers: [Technique with new configuration; armrest and footplate management]
• Component Management: [Charging; cushion care; maintenance]
• Emergency Procedures: [Response to device failure or medical symptoms]
• Competency Verification: [return demonstration / supervised trials / caregiver teach-back]; [Barriers to learning and mitigation]

Follow-up Schedule

• Initial Follow-up: [Timeframe, typically 2–6 weeks post-delivery]
• Periodic Reassessment: [Frequency]
• Triggers for Earlier Follow-up: [New pain; redness or wounds; weight change greater than 10 pounds; functional decline; falls; repeated repairs]

Attestation

Clinician Attestation: The recommendations in this report are based on clinical evaluation findings and are medically necessary to meet the identified functional and safety goals.

Evaluating Clinician Signature: [Signature and date] (If signature cannot be obtained at time of note completion, document status and route for completion.)