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Amputee Assessment Mobile App

The Amputee Assessment mobile app provides a checklist that represents items the Centers for Medicare and Medicaid Services (CMS) have required to be documented in the medical record for all patients who are to receive a prosthetic device. Having these items documented in your patient’s medical record will help to ensure that your patient will receive the necessary prosthetic devices and to ensure that the prosthetist will be reimbursed from CMS.

You can easily document muscle strength, body weight, emotional well-being and quality of life, and the prosthetic rehabilitation process. All documentation is saved in the GoCanvas Cloud and can be printed or emailed as a PDF if you want to use it during follow-up care with the patient and any physical therapist. This app can be downloaded to an iPhone, iPad, or Android device.

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Take a peek inside the Amputee Assessment Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

The following checklist represents items that the Centers for Medicare and Medicaid Services (CMS...
Documentation in Prescribing Physician’s Medical Records
Please use the following checklist to indicate that the item has been properly documented in your...
Physical Examination
Weight & height
Cardiopulmonary exam
Arm/leg strength & ROM
Neurologic exam
Gait assessment
Balance and coordination
Amputation History
Diagnosis/cause of amputation
Date of amputation(s)
Amputation level
Prognosis
Patient’s Functional Status
Description of ADLs and their impact by deficit
Diagnoses causing ADL deficits
Other comorbidities related to ambulation deficits or that could impact use of new prosthetic device
Current ambulatory assistive devices used by patient
Patient’s functional status prior to amputation
Patient’s current functional capabilities
K-level assigned to patient’s current functional capabilities
Patient’s expected functional potential
K-level assigned to patient’s expected functional capabilities
Explanation for difference between current and expected functional capabilities
Current status of residual limb
Status of current prosthesis/component(s)
...and More!