Trans Tibial
Initial Eval
Foot Orthotics
Initial Eval
1 - Note Section:
Px
Weight in lbs
Gender
Pick One
Male
Female
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Patient Age
Patient Height
Other relevant information for Px
2-Note Section:
Dx
BKA Common Dx
Z89.512 Acquired absence of left leg below knee
2Z89.511 Acquired absence of right leg below knee
E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified
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Other Dx not listed
3 - Note Section:
Rx
BK Perscription
Right TT Replacement socket
Left TT Replacement socket
Right TT leg (Foot and socket)
Left TT leg (foot and socket)
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Other Rx:
4 - Note Section:
Hx:
Date of amputation
cause of amputation
Pts first prosthetic device
Yes
No
Previous Prosthetic devices
Daily activities/hobbies/responsibilities
Work
Fulltime
Part time
retired
disabled
Past and present Employment
Living situation (home barriers)
Primary caregiver
Physical Condition
morbidly obese
overweight
fair
thin
very thin
Current Medication/Alergies
average hrs of sleep
recent falls
Is pt motivated to walk?
No
Yes
Extremely motivated
Additional relevant information for hx:
5 - Note Section:
Ax
Pt K-Level
K0
K1
K2
K3
K4
K-level justification (medicare)
The patient does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility.
The patient has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence.
The patient has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs or uneven surfaces.
The patient has the ability or potential for ambulation with variable cadence. pt has the ability to traverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands prosthetic use beyond simple locomotion.
The patient has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress or energy levels.
Standing stability w/o prosthesis
Residual limb shape
Residual Limb condition
Excessive soft tissue
Excessive scarring
skin grafts
abrasions/blisters
currently infected
edema
frequent volume changes
phantom pain
instability
manual muscle testing
range of motion
pt goals
6 - Note Section:
Sx:
BK initial eval appointment activities
Initial Eval
Casting
scan
left shrinker for pt
educated pt on shrinker usage
educated pt on next steps
Other relevant information for sx:
7 - Note Section:
Ppx:
suspension type
Pin system
suspension sleeve
elevated vacuum
liner type
6 mm
3 mm
Other
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TT liner (other)
Option 1
Option 2
Option 3
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prosthetic foot
socket thickness
standard layup
thick layup
standard plus felt
Other relevant information for ppx:
8 - Note Section:
Rtn:
Next TT appointment
will contact pt to schedule once check socket has been recieved
follow up apt set
follow up with pt once healed
follow up with pt once authorization is revieved
Next appointment date
