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Run: Upper Extremity Orthotic Fabrication Log

Track custom upper-extremity orthosis fabrication, fit checks, wearing schedule, adjustments, and patient education in one clinical log. Use it to document w...

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Submission Notice

Purpose of this log

Patient identifier (required)

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 (required)

Orthosis Fabrication Details

Orthosis / splint type (required)

If other, specify orthosis type (required)

Fabrication materials used (required)

If other, specify materials (required)

Joints positioned during fabrication (required)

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 (required)

Fit status (required)

Fit check notes

Document pressure areas, alignment, skin tolerance, and any issues observed during fit check.

Wearing schedule (required)

Provide clear instructions for wear duration, frequency, and any progressive wear schedule.

Patient education provided (required)

Education notes

Document patient understanding, teach-back, caregiver involvement, or any additional counseling.

Adjustments and Follow-Up

Adjustments made (required)

Adjustment details

Describe modifications such as heat molding, strap repositioning, padding changes, or trim line adjustments.

Follow-up needed (required)

Follow-up date (required)

Follow-up plan

Document reassessment goals, skin check plan, or expected next steps.

Audit Trail

Clinician name (required)

Enter the name of the clinician completing this record.

Clinician role (required)

Attestation (required)

Yes No N/A

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Email (required)

Your name (optional)

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