Lymphedema measurement form 2025

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Stage 0:The affected area may feel swollen, tight and heavy but without outside signs of swelling. Stage I: There may be occasional swelling that goes away when you elevate the affected area. Stage II: The affected area is almost always swollen and your skin in the area may feel firmer than the surrounding area.
Stage 1 is early edema, which improves with limb elevation. Stage 2 represents pitting edema that does not resolve with elevation. Stage 3 describes fibroadipose deposition and skin changes. The severity of lymphedema is categorized as mild (40%).
Measuring swelling using a tape measure Starting with a point on your hand or foot, they make marks at regular intervals up your arms or legs. They measure around the limb (the circumference) at those intervals. They call these circumferential limb measurements.
Stage 3 (Severe Lymphedema/Elephantiasis): Extreme swelling with significant skin changes, including thickening, hardening, and wart-like growths.
Stage 0: No swelling, but pathological lymphoscintigram (latency stage). Stage I: Edema of soft consistency, elevation reduces swelling (spontaneously reversible stage). Stage II: Edema with secondary increasing tissue changes, elevation has no effect; (spontaneous irreversible stage).

Facts about lymphedema measurement form

The lymphedema measurement form is a crucial tool for healthcare providers to assess and document the condition of patients suffering from lymphedema, ensuring they receive appropriate treatment.

Use cases of the form

Form filing requirements

How to submit the lymphedema measurement form?

Other important aspects to understand about completing lymphedema measurement form

Use cases of the form

This form is primarily utilized by healthcare professionals, including physicians, physical therapists, and wound care specialists. It is essential for individuals diagnosed with lymphedema who require compression therapy or other treatments. For instance, a physician may need to complete this form to prescribe a compression pump for a patient recovering from cancer surgery that has led to lymphedema. Additionally, it can be used in rehabilitation centers where patients are monitored for their recovery progress.

Form filing requirements

To file the lymphedema measurement form, it must be completed accurately and submitted along with any necessary prescriptions. There are no specific deadlines for submission; however, timely filing is recommended to ensure prompt treatment. Documentation such as medical history and previous treatment records may also be required.

  • Complete all sections of the form thoroughly.
  • Attach any relevant medical documentation.
  • Ensure the treating physician's signature is included.

How to submit the lymphedema measurement form?

Submitting the lymphedema measurement form involves several steps: first, obtain the template either online or through your healthcare provider. Next, fill out the form completely with accurate measurements and patient information. After completing the form, fax it along with any required prescriptions to the designated number provided on the document.

  1. Obtain the lymphedema measurement form template from DocHub or your healthcare provider.
  2. Fill out all required fields accurately.
  3. Gather any additional documentation needed for submission.
  4. Fax the completed form and accompanying documents to NR at 1-800-749-0711.

Other important aspects to understand about completing lymphedema measurement form

It is vital that measurements are taken correctly using a standard measuring tape to avoid errors in treatment equipment sizing. The best time to take these measurements is in the morning or immediately after compression therapy when swelling is minimized. Furthermore, if custom sleeves are ordered without proper measurements, costs associated with reordering will not be covered by NR.

  • Accurate circumference measurements are critical for effective compression therapy.
  • Patients should inform their healthcare provider about any changes in their condition before submitting this form.
  • 'Bilateral conditions' require both sides of the body to be measured and documented on this form.
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Each item is scored with a 5-point Likert scale ranging from 0 to 4, except item 18 (infection occurrence), with higher scores representing greater severity of impairment. Item 18 concerns the number of infection occurrences in the past year and has its unique domain with 5 response categories scored 0 to 4+.
Signs and symptoms of lymphedema include distal swelling in the extremities, including the arms, hands, legs, feet; swelling proximally in the , chest, shoulder, pelvis, groin, genitals, face/intraoral tissues; restricted range of motion in the joints because of swelling and tissue changes; skin discoloration;
The accepted gold standards for measuring limb volume change in the clinical environment are water displacement volumetry and circumferential limb measures. The most common criterion for lymphedema diagnosis is a volume difference of 200 mL.

lymphedema evaluation form