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Run: Upper Extremity Orthotic Fabrication Log

Track the fabrication, fit check, adjustments, wear schedule, and patient education for a custom upper-extremity orthosis in one place. Use it to document wh...

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Submission Notice

Purpose of this log

Consent for clinical documentation and follow-up recorded (required)

Confirm that the patient was informed about documentation and any follow-up communication related to this orthosis.

Yes No N/A

Patient and Order Details

Patient identifier (required)

Use the medical record number or internal patient ID. Avoid entering sensitive identifiers unless required by your workflow.

Date of fabrication (required)

Referring provider or service

Side (required)

Orthosis Fabrication Details

Orthosis / splint type (required)

If other, specify splint type

Fabrication material (required)

If other materials were used, describe them

Joints positioned during fabrication (required)

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 (required)

Fit check date

Pressure areas or skin concerns identified (required)

Yes No N/A

Describe pressure areas or skin concerns

Adjustments made

Document trimming, remolding, padding changes, strap changes, or other modifications.

Follow-up fit check needed (required)

Wear Schedule and Patient Education

Wearing schedule (required)

If other, describe the wearing schedule

Wear and care instructions provided (required)

Patient education notes

Summarize education provided, patient understanding, and any teach-back performed.

Clinician Sign-Off

Clinician name (required)

Clinician role (required)

Clinician signature (required)

Get your results

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Email (required)

Your name (optional)

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