Initial Evaluation

Patient Name:

DOB:

Referring Physician: TBD

Date of most recent visit: TBD

Date and Time:

Prescription:

Diagnosis and ICD-10 codes(s):

Reason for visit:

Medical Hx

• Amputation Hx:
• Prior medical conditions/surgeries:
• Current medications (and purpose):
• Fall/stumble history:
• Progress of rehabilitation or recovery:

Subjective

P&O intervention history:

Preferences:

• Patient Activity/Participation Goals and ranking of current ability

Patient Specific Functional Scale
	Today’s Date	Date	Date	Date
Goal/activity #1
Goal/activity #2

Objective:

Today’s activities:

Age:

Height:

Weight: (note if self-reported)

Handedness:

Cognitive ability:

MMT:

ROM:

Contralateral side:

Residual/affected limb

(R or L) Limb measurements
	Circumferences without interface
	date	date	date
Lat epicondyle to end
2”
4”
6”

• Shape
• Muscle tone
• Skin and mobility of skin
• Circulation
• Neuromas
• Sensation
• Pressure tolerance/tolerance to forces
• Joint laxity

Posture:

Objective assessment of ADLs:

Assessment:

Prosthetic Goals:

• Barriers
• Facilitators

Prescription Recommendation

L-code table with justifications

Plan:

• Short-term plan
• Long-term plan

Patient family education:

Return appointment:

NAME, CREDENTIALS

DATE

INSTRUCTIONS in RED and ITALICS – do not include these instructions in your assignment.

INITIAL EVALUATION (delete the italics)

Patient Name: Use first name and last initial only for class assignments

DOB: Date of Birth

Referring Physician: OK to state TBD since this is a class assignment

Date of most recent visit: N/A

Date and Time: Document length of visit, esp. relevant for time and repair codes

Prescription: Transradial upper limb prosthesis, Left or right side, bilateral

Diagnosis and ICD-10 codes(s): Complete traumatic amputation at level between elbow and wrist,

ICD-10 code = if R – S58.111S, if L – S58.112S (https://www.icd10data.com/ICD10CM/Index/A/Amputation)

Reason for visit: Brief statement of service provided (E.g., Patient was seen for initial evaluation and casting for R/L transradial prosthesis.)

Medical Hx History of the present condition(s) and past medical history, only include if relevant to functional need. Bullet points.

• Amputation Hx: type of amputation and any significant information about the surgery, side of the amputation and date of the amputation. If relevant, state the cause and the mechanism of injury. Please include the position of the shoulder when injured. This may help you understand the subsequent nerve injuries.
• Prior medical conditions/surgeries
• Current medications (and purpose)
• Fall/stumble history
• Progress of rehabilitation or recovery, include any therapy intervention

Subjective

The subjective data includes the patient’s perspectives about their feelings, thoughts, personal and functional goals, preferences, and relevant positive/negative statements stated by the patient. Write in paragraph format and organize by ICF.

Activity/Participation: State the person’s current self-reported activity level and other important activities they perform when a prosthesis might be useful. Examples of participation include: interpersonal relationships, employment, and community, social and civic life. Describe the environment where the person will use their prosthesis.

Personal factors: Briefly state the pts social support system, education, if military service/veteran status and any other personal factors.

Body functional status:

• Pain, type/location: only include if relevant

• P&O intervention history, current device: E.g., what has been tried and what has and has not worked for this pt.
• Socket fit: socket comfort scale
• Alignment of orthosis/prosthesis
• Description and photo

Preferences: Record the patient’s preferences: function, comfort, cosmesis, reliability, cost. Ask them to clarify their top two priorities and provide examples.

• Patient Goals and ranking of current ability (table format works well here)

Patient Specific Functional Scale
	Today’s Date	Date	Date	Date
Goal/activity #1
Goal/activity #2

Objective:

The objective section includes your observations and measurable data. Format this section so that the data is easy to access! Use tables and bullet points.

• Today’s activities: describe what you did today. E.g., pt was evaluated and casted for (R or L) transradial prosthesis. The casting procedure was well tolerated. Include all communication with other care providers and education provided to the patient.

• Age, sex, gender, height, weight (note if self-reported)
• Handedness

• Cognitive ability, e.g., Speaks in full sentences. Fair recollection of recent/past events. Somewhat tangential.
• MMT: E.g., normal strength at shoulder, elbow, wrist and hand joints, expect 3/5 R shoulder abduction
• ROM: E.g., WNL at all shoulder, elbow, wrist and hand joints, except R shoulder abduction limited at 45’

• Condition of contralateral side
• Note any conditions that may limit performance, such as joint laxity

• Condition of residual/affected limb
• Length (in cm and % of contralateral side)
• Surgical scar (intact, no drainage)
• Shape (conical, bulbous, cylindrical, elliptical, edematous)
• Soft tissue coverage (bony, redundant tissue, atrophic, firm muscle tone)
• Skin/Dermatological issues (intact, dry, no rashes or ulcerations) and mobility of skin
• Temperature (warm, cool, moist dry, cyanotic)
• Neuroma location ________________
• Sensation light touch (intact, impaired, or absent)
• Position Sense (intact, impaired, or absent)
• Palpation and tolerance to force couples (e.g., medial lateral sides of limb, distal end of limb, supracondylar, epicondyles, deltopectoral groove, etc.)

• Posture
• Objective assessment of ADLs (include your observations here, e.g., report kinesthetic compensations, timing, accuracy)

Assessment:

Use the Example template on next page of this document! This section is a synthesis of the data. This is where you write your interpretation and impression of the problem/need, the goal, the proposed prescription and justification

Prosthetic Goals the desired functional outcomes), importance to pt, and how will P&O make a difference.

Prescription Recommendation Short description of prosthesis/orthosis, stage of care, design, and components.

L-code table with justifications

Plan:

Describe what you intend to do: a) clinical, b) technical, c) administrative and d) interdisciplinary plans. The prosthetic plan includes both short-term and long-term considerations.

• The short-term plan includes the intentions for the next appointment as well as any planned interdisciplinary coordination and communication. For example: Plan to see the pt next week for fitting of a test socket. Plan to contact the Occupational Therapist to discuss the goals and timeline of the prosthetic treatment plan.
• The long-term plan may be 1 year out or 5 years out. It may be something like, ‘maintain strength, endurance, activity and participation level’, but must be more specific to the patient’s goals. This plan may still be under development.

Patient family education: In this section include any patient related instructions.

Return appointment: State the date for the return appointment.

NAME, CREDENTIALS

DATE

The next four pages provide instructions for writing the A section of the notes.

Assessment Section of Chart Note: Upper Limb Prosthetic Example

The assessment section is a synthesis of the subjective and objective data. This is where you write your interpretation and impression of the activity/limitation problem, the goal, the proposed prescription and justification.

• Describe the patient, Dx, level of independence.

Pt is a __(A)__ yo male/female who is motivated to maintain his/her activity level. He/she (dx of) ________(B)_________ since ___(C)___ . She/he enjoys ______(D)_______.

• A: age
• B: Dx, Note only the relevant medical diagnoses.
• C: time since diagnosis, time since amputation
• D: level of independence (independent, home with assist, assistive living)
• ULP: Ms. G. is a healthy active 35 yo motivated to maintain her activity level. She has a Rt transradial amputation. She lives alone and performs all the maintenance around her home, such as housework and yard work. She enjoys cooking and going out with friends.

• Describe the physical condition and/or gait analysis.
• His/her _____(A)_____ .
• A: Physical objective results that do not fit normative values.

ULP: Her residual limb is healthy, and length is 35% of contralateral side. Her shoulder flexion ROM is limited to 90’.

• Describe the root cause of the functional limitation/restriction: biomechanical impairments and interpretation of outcome measures. – What is the source of the problem?
• Pt presents with (difficulty, a limited ability to or unable to) ________(A)_________ , which significantly impairs their ability to ________(B)_________ (without the use of the prosthesis/orthosis or with a different type of socket/component). This activity limitation is due to ________(C)_________.
• A: General limitations, e.g., walk, balance, mobility, gait (velocity, symmetry), balance, confidence, pain, endurance.
• B: Functional limitation/restriction, e.g., perform ADLs: toilet, feed, dress, groom, and bath, fulfill job responsibilities including …., or engage in x/y recreational activities
• C: Impairments, e.g., ROM, strength, alignment, balance, endurance, and coordination. Support your reasoning with results from outcome measures.

ULP: She owns a business and needs to be able to use both arms to lift objects and do small construction activities. E.g., She is unable to independently hammer a nail due to the inability to gasp small objects with her right arm; and she is not able to carry large boxes (25lbs) and chairs due to lack of opposition with her left arm further away from her body.

• State the prosthetic/orthotic goals: the desired outcomes.
• Goal: To improve ____ (A)____.
• A: prosthetic/orthotic goal(s) (this is the same as the functional limitation/restriction, also the construct of interest for your outcome measure.)

ULP: To improve her ability to use both arms to lift objects and do small construction activities.

• State how the biomechanical controls/intervention will directly address the functional impairments and limitations including the medical necessity for the service.
• Specifically, the prosthesis/orthosis will ____ (A) ____. Overall, the prosthesis/orthosis will improve his/her ____ (B) ____ and maintain the patient’s level of activity and participation long-term
• A: Describe the control, biomechanical controls, or technical details (e.g., heavy duty)
• B: Health. E.g., cardiovascular condition, balance and stability, prevent falls, ADLs

ULP: Specifically, the prosthesis will improve her ability to: 1) hold nails while hammering, 2) use both arms to carry long pieces of lumbar, 3) stabilize boards with the Rt arm while using the saw with the Lt, and 4) stabilize the roof tiles while using the staple gun in the Lt hand. The prosthesis will maintain the patient’s ability to perform her activities and participate with others long-term.

• Potential mobility (or K-level) and the facilitators and barriers to achieving the functional goal.
• With use of the prosthesis/orthosis, his/her mobility is__(A)__ (on the Medicare Functional Classification Level). The pt has ____B) ____ potential to perform the functional activities (or state the activity/participation) because ____(C) ____. State barriers if they exist. If PT/OT is necessary, state this in the Plan section, not this Assessment section of the chart note.
• A: State the expected functional potential (i.e., K-level). If needed, explain the difference between current functional capabilities and his/her expected functional potential. Functional levels: household ambulator, exceeds basic ambulation skills, limited community ambulator, unlimited community ambulator, exhibiting high impact, stress or energy levels.
• B: excellent, very good, good, fair, poor
• C: Facilitators, motivation; early in rehab process – good likelihood of muscle function return; fitness: previously healthy, high fitness level; environment: supportive family and/or friends, accessible home, boss willing of light duty, previous use of prosthesis.
• Example barriers: pain, residual limb condition, lack of funds or insurance coverage, pain, need for strengthening or increase in ROM and endurance, potentially unrealistic expectations, contralateral side problems etc.

ULP: With the use of the prosthesis, the pt can maintain her level of independence. The pt highly motivated to regain her independence.

• Rx recommendation and L-code table with justifications
• Prescription Recommendation = one sentence description of prosthesis/orthosis including design, and components.

ULP: Body-powered definitive transradial prothesis with a hinged style socket, 5X TD, FM quick disconnect wrist unit, figure-8 harness and Bowden cable.

• L-code table = Provide patient-specific information. Your explanations must provide defensible justification and convince the reader that each billing code is reasonable and necessary.
• Patient-specific examples: e.g., heavy duty, reliable, lightweight, safe ambulation, falls, balance, cardiovascular health, requirements for stabilization for the foot and ankle for medical reasons, low cost, etc.
• Explain the biomechanical rational and the biomechanical purpose (e.g., corrective forces, ground reaction forces, support, gait) of the orthosis/prosthesis.
• State the patient’s priorities, include specific activities of what the patient will be able to do. Allow the reader to visualize the purpose of each part/code.

Add-on

Include logical justifications for each element of the proposed Rx.

• Consider compatibility of components (e.g., metric vs standard threads for the TD and wrist unit).

• Put it all Together

ASSESSMENT

Ms. G. is a healthy active 35 yo motivated to maintain her activity level. She has a Rt transradial amputation. She lives alone and performs all the maintenance around her home, such as housework and yard work. She enjoys cooking and going out with friends. Her residual limb is healthy, and length is 35% of contralateral side. Her shoulder flexion ROM is limited to 90’. She owns a business and needs to be able to use both arms to lift objects and do small construction activities. E.g., She is unable to independently hammer a nail due to the inability to gasp small objects with her right arm; and she is not able to carry large boxes (25lbs) and chairs due to lack of opposition with her left arm further away from her body.

• Prosthetic goal: To improve her ability to use both arms to lift objects and do small construction activities, the pt requires a R transradial prosthesis. Specifically, the prosthesis will improve her ability to: 1) hold nails while hammering, 2) use both arms to carry long pieces of lumbar, 3) stabilize boards with the Rt arm while using the saw with the Lt, and 4) stabilize the roof tiles while using the staple gun in the Lt hand. The prosthesis will maintain the patient’s ability to perform her activities and participate with others long-term. With the use of the prosthesis, the pt can maintain her level of independence. The pt highly motivated to regain her independence.

RX recommendation:

Body-powered definitive transradial prothesis with a hinged style socket, 5X TD, FM quick disconnect wrist unit, figure-8 harness and Bowden cable.

L-code table with justifications

Use this table to report your suggested Rx in the assessment section of your chart note.

Qty	Code	Modifier	Description	Justification
	leave this column blank	Rt or Lt	Transradial prosthesis	State (again) the overall purpose of the prosthesis. E.g., The transradial prosthesis is necessary to provide the pt the ability to carry large boxes with both arms, grasp small objects with her right TD and perform bimanual tasks, such as hammering nails and cooking.
			Test socket	E.g., A test socket is necessary to ensure a well-fitting, supportive prosthetic socket and prevent potential skin problems.
			Suspension system State type of suspension	Suspension: Will the prosthesis be suspended through the harness, or the socket, or a pin? Describe this and explain why you are recommending this type of suspension. E.g., The harness is necessary for suspension of the prosthesis and for body powered control of the TD.
			Control system State the control	Control Mode: are you recommending body powered or externally powered? Why E.g., Body powered cable is necessary to transfer the body movement to operate the TD. It allows the patient to maintain direct sensory feedback while performing yardwork so that he is aware of how much pressure he is exerting on plants or tools. It is suitable for heavy duty activities, low cost, reliable, and lightweight
			Terminal Device: State the specific TD	Terminal Device: explain why you are choosing the TD. Why model 5XA instead of model 5, instead of a hand. If you are recommending more than one TD, you must explain why it is necessary to meet the patient’s needs. E.g., The Model 7 Work Hook will stabilize nails for hammering, hook bag handles for carrying, and grasp large items during bimanual work such as when carrying long boards and saws. The Model 7 Work Hook is durable and able to withstand the needs as the pt needs to lift heavy (50lbs) objects.
			Wrist unit: State the specific wrist	Wrist Unit: Describe why you are recommending a particular wrist unit. E.g., the quick disconnect wrist unit will allow the pt to easily exchange TDs from the model 5 to the golf TD. This also provides a variety of locked pronation/supination positions, for instance as the pt is maneuvering a chainsaw at work.
			Elbow unit: State flexible or rigid	Elbow joints: Are you recommending elbow joints? Why? E.g., the heavy-duty rigid elbow joints are necessary for the pt. These will resist the rotational forces between the socket and his limb and they will allow for transmission of force from his limb to the full humeral cuff as he is working with machinery on his farm. This allows him to lift heavy items while protecting his residual limb. E.g., the flexible hinges will allow the pt to maintain pronation/supination positioning of the prosthesis in space, reducing the need to passively position the TD.
			Socks/liners (if needed)	Prosthetic Socks/sheaths: does the patient need socks? You must describe why they need socks. If suggesting socks, provide 6 so some can be in the wash while the pt wears the prosthesis. E.g., The socks provide a barrier between the limb and the socket reducing shear and helps to distribute socket forces.
			Standard or Heavy duty	Materials: if heavy-duty materials are needed, provide reasons why. Eg, patient works outdoors lifting manhole covers, 75lbs, therefore heavy-duty cable and carbon layup in the prosthesis are necessary for durability.
			Special modifications	Explain the modifications and why you are adding any special modification.

Why are justifications necessary?

The justifications explain how the prosthesis will help the patient achieve his/her desired activities. It is important to describe how you expect the prosthesis (or its components) to influence the patient’s activities and participation. Include compelling statements about the need for each of the components and the design that you are recommending. This information is critical. It must convince the reader that these components are the appropriate choice to meet the patient’s needs.

The justifications keep us accountable for our work. You must evaluate the effectiveness of your intervention before and after the fitting appointment. During follow up appointments, you will re-evaluate the prosthesis to assess if the prosthesis is meeting the prosthetic goals. If the components are not adequate, then you would re-evaluate your decisions and make changes to the prosthesis, if possible.

Each element of the prosthesis has its own patient-centered justification.