Get Physician Prosthetic Assessment

The Physician Prosthetic Assessment is an essential document designed to evaluate a patient's need for a prosthetic device. This comprehensive guide will walk you through each section of the form, ensuring a complete and accurate submission to enhance patient care.

Follow the steps to accurately complete the assessment form.

1. Press the ‘Get Form’ button to receive the assessment form and open it in your chosen editor.
2. Fill in the patient information section, including the patient's name, sex, date of birth, height, and weight.
3. In the 'Medical Necessity' section, indicate any comorbidities that may affect the patient’s mobility and ability to function with a prosthesis. If applicable, provide a brief explanation.
4. Specify if the patient is able to benefit from a prosthesis for daily activities by selecting 'Yes' or 'No' for both the right and left limbs.
5. If the patient currently has a prosthesis, briefly explain the reasoning for its replacement. If the patient does not have one, check the appropriate box and proceed to the next section.
6. In the 'Desire to function with a prosthesis' section, detail how the patient has communicated their desire for a prosthetic device.
7. In the 'Ability to function with a prosthesis' section, check all aids the patient currently uses for mobility, and provide any relevant information about their demonstrated potential to function with a prosthesis.
8. List any aids that the patient may require after fitting with a prosthesis.
9. For the 'Current and Expected Functional Level,' select the appropriate K levels for both the current and expected state. Provide an explanation if they differ and describe the patient's expected activities of daily living.
10. In the 'Multi-Discipline Corroboration' section, consider and check all relevant healthcare professionals who contributed to the assessment.
11. Conclude by providing additional comments or observations if necessary, printing the physician’s name and obtaining their signature.
12. Finally, save your changes, and you may also choose to download, print, or share the completed form.

Complete your Physician Prosthetic Assessment online to ensure comprehensive evaluation and care.