Upper Extremity Orthotic Fabrication Log

Log custom upper-extremity orthotic fabrication details, fit checks, adjustments, wearing schedule, and patient education.

Submission Notice

• Purpose of this log
• Consent for clinical documentation and follow-up recorded
  Confirm that the patient was informed about documentation and any follow-up communication related to this orthosis.

Patient and Order Details

• Patient identifier
  Use the medical record number or internal patient ID. Avoid entering sensitive identifiers unless required by your workflow.
• Date of fabrication
• Referring provider or service
• Side

Orthosis Fabrication Details

• Orthosis / splint type
• If other, specify splint type
• Fabrication material
• If other materials were used, describe them
• Joints positioned during fabrication
  Select all joints intentionally positioned or immobilized by the orthosis.
• Positioning details
  Document target angles, alignment goals, or any clinically relevant positioning notes.

Fit Check and Adjustments

• Initial fit status
• Fit check date
• Pressure areas or skin concerns identified
• Describe pressure areas or skin concerns
• Adjustments made
  Document trimming, remolding, padding changes, strap changes, or other modifications.
• Follow-up fit check needed

Wear Schedule and Patient Education

• Wearing schedule
• If other, describe the wearing schedule
• Wear and care instructions provided
• Patient education notes
  Summarize education provided, patient understanding, and any teach-back performed.

Clinician Sign-Off

• Clinician name
• Clinician role
• Clinician signature