Click-to-copy orthotic management documentation for PTs and PTAs in skilled nursing. Free, no login.
Orthotic/Prosthetic Mngmt: adjustments to device to ensure proper body alignment, analysis of skin for irritation, areas of pressure or breakdown after initial fitting, orthotic management and training, including design and fitting, orthotic fitting/design w/emphasis on maintaining skin integrity, instruction in proper use, care and wearing time of device, design and fitting of static orthotic device, design and fitting of dynamic orthotic device, analysis/checkout of patient's response to wearing orthotic/prosthetic device, instruction in proper use, care and wearing time of prosthetic device, instruction in therapeutic exercise to facilitate ability to wear orthotic device w/o complications, analysis of caregiver follow-through in proper donn/doff, care and wearing time of device, therapeutic assessment of proper fit during functional activity performance, therapeutic assessment of patient's tolerance to dynamic forces applied, analysis of response to modification of devices, analysis of patient's response to positioning adjustments, techniques to inhibit abnormal movement patterns, techniques to decrease influence of pathological reflexes, techniques to prevent contractures, techniques to normalize tone, facilitation of normal movement, therapeutic stretch techniques, techniques to prevent skin breakdown, techniques for pressure distribution, facilitation of proper body alignment, facilitation of postural control, techniques to decrease pathological reflexes, techniques to improve functional skill performance, techniques to improve stability, techniques to improve time out of bed, techniques to facilitate cardiopulmonary function, edema reduction, control & management techniques, techniques to promote safety, techniques to decrease & manage pain, proprioceptive & kinesthetic facilitation techniques and analysis of need for additional padding, underwrap or socks.
Patient fitted with a --- AFO on the --- LE; skin inspected after --- min of wear and found --- . Wear schedule established at --- hours.
Patient ambulated ---ft with the new --- AFO at ---A; toe drag reduced from --- to --- and step clearance improved.
Patient and caregiver educated on AFO donning and doffing; caregiver returned demonstration with --- accuracy.
Patient's AFO inspected this date; --- noted at the --- strap. Orthotist notified for adjustment.
Patient's skin inspected following --- hours of AFO wear; --- redness noted at --- , resolving within --- min of removal.
Patient trialed a --- vs a --- AFO; the --- provided superior --- and was recommended for permanent fitting.
Patient fitted with a --- knee brace set at --- degrees flexion per MD order; patient verbalized the restriction with --- accuracy.
Patient's AFO wear schedule progressed from --- to --- hours per day based on skin tolerance and functional benefit.
Patient trialed a shoe lift of --- inches on the --- LE to address a --- inch leg length discrepancy; pelvic obliquity reduced.
Patient fitted with a resting hand splint on the --- UE; wear schedule of --- hours established and nursing educated.
Patient educated on sock and shoe requirements with the AFO; patient verbalized that a seamless sock and a --- shoe are required.
Patient's orthotic discontinued this date 2/2 --- ; PT notified the MD and documented the rationale.
Patient fitted with a --- lumbar orthosis per MD order; patient returned demonstration of donning in supine with --- accuracy.
Patient's AFO adjusted this date to --- degrees DF to improve stance stability; patient ambulated ---ft with improved ---.
Patient's orthotic reassessed following a --- lb weight change; refitting recommended and the orthotist was notified.
Patient ambulated ---ft with vs ---ft without the AFO, demonstrating the functional benefit of the orthosis.
Patient reports the AFO is --- ; PT assessed and identified --- as the cause and initiated --- .
Patient's compression garment donned with a donning aid; patient required ---A and returned demonstration with --- accuracy.
Patient educated on the expected lifespan of the orthosis and the signs that indicate replacement is needed.
Patient's AFO integrated into the gait training program this date; skilled PT is required to assess the interaction of the orthosis with the gait pattern.
Patient's --- orthosis inspected and cleaned; nursing educated on the daily cleaning and inspection protocol.
Patient fitted with a heel offloading boot to protect a stage --- ulcer; nursing educated on wear and skin inspection.