Upper Extremity Orthotic Fabrication Log

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

Submission Notice

• Purpose of this log
• Patient identifier
  Use the minimum necessary identifier used by your organization (for example, MRN or chart number). Avoid collecting SSN or full DOB unless required by policy.
• Date of service

Orthosis Fabrication Details

• Orthosis / splint type
• If other, specify orthosis type
• Fabrication materials used
• If other, specify materials
• Joints positioned during fabrication
  Select all joints intentionally positioned or immobilized by the orthosis.
• Fabrication notes
  Include trim lines, padding locations, strap placement, or other clinically relevant fabrication details.

Fit, Wearing Schedule, and Patient Education

• Fit check completed
• Fit status
• Fit check notes
  Document pressure areas, alignment, skin tolerance, and any issues observed during fit check.
• Wearing schedule
  Provide clear instructions for wear duration, frequency, and any progressive wear schedule.
• Patient education provided
• Education notes
  Document patient understanding, teach-back, caregiver involvement, or any additional counseling.

Adjustments and Follow-Up

• Adjustments made
• Adjustment details
  Describe modifications such as heat molding, strap repositioning, padding changes, or trim line adjustments.
• Follow-up needed
• Follow-up date
• Follow-up plan
  Document reassessment goals, skin check plan, or expected next steps.

Audit Trail

• Clinician name
  Enter the name of the clinician completing this record.
• Clinician role
• Attestation