Orthosis/Splint Fabrication & Training Procedure Note

Date of Service: [Date and time if required by setting]

Clinician: [Name, credentials]

Discipline: [OT / PT / Hand Therapy]

Setting: [outpatient / inpatient / home health]

Encounter Type: [initial orthosis encounter / subsequent adjustment and training]

Post-Op/Injury Day: [Post-op day or weeks post-injury] (Include only if applicable.)

Referring/Ordering Clinician: [Name, credentials] (Include only if applicable.)

Procedure Summary

[Laterality], [anatomical region] [orthosis/splint type or category], [custom fabricated / prefabricated and adjusted], for [immediate clinical purpose: immobilization / protection / positioning / deformity prevention / pain reduction / protocol adherence]. (1–3 sentences summarizing what was done and why.)

Indication and Medical Necessity

Primary Diagnosis/Condition: [Diagnosis with stage: acute / chronic / post-op protocol]

• Key impairments driving need: [pain / edema / instability / tendon protection / limited ROM / spasticity / contracture risk]
• Functional problem addressed: [Functional limitation the orthosis mitigates]
• Skilled orthosis management required because: [custom fit needs / positioning requirements / education complexity / comorbid risks such as sensory loss or skin fragility]
• Plan of care alignment: [Reference related goal IDs or short names] (Reference only; do not restate entire goals.)

Precautions Considered

• Skin integrity concerns: [present / absent] – [Findings if present; mitigation: extra padding, edge flaring, shortened break-in, earlier follow-up]
• Sensation deficits/neuropathy: [present / absent] – [Screen result and mitigation if present]
• Circulatory compromise risk: [present / absent] – [Findings and mitigation if present]
• Cognitive/communication barriers: [present / absent] – [Caregiver involvement or teaching adaptations if present]
• Material allergies/sensitivities: [present / absent] – [Material selection changes if present]

Pre-Fabrication/Pre-Fit Findings

• Pain score (0–10): At rest [#], with movement [#] (Include only if relevant to fit or safety.)
• Edema: [Location and character relevant to contact and strap areas]
• Skin condition at planned contact areas: [intact / fragile / wound / incision / healed scar]
• Sensation screening: [intact / diminished / absent] – [Method] (Include only if relevant to orthosis type.)
• Required protective position/ROM limits: [Position and angles as required by protocol or clinical need]
• Baseline neurovascular status: [color / temperature / capillary refill / swelling] (Include only if indicated by orthosis type or compression risk.)

Orthosis Details

• Orthosis name/type: [e.g., resting hand / wrist cock-up / thumb spica / mallet finger / elbow extension]
• Fabrication type: [custom fabricated / prefabricated and adjusted]
• Orthosis class: [static / static-progressive / dynamic]
• Orientation: [dorsal / volar / circumferential]
• Base configuration: [forearm-based / hand-based / finger-based / elbow-based]
• Laterality: [left / right / bilateral]
• Joints immobilized: [List joints]
• Joints left free: [List joints]
• Target position: [Specify angles and positions for relevant joints]
• Materials: Base [material and thickness], Strapping [type], Interface [padding or liner], Components [outriggers / hinges / dynamic elements if applicable]
• Key measurements: [Measurements relevant to fit] (Include only if tracked in your practice.)

Fabrication Process

(Include this section only if custom fabrication was performed; omit entirely for prefabricated devices.)

• Method: [molded on patient / fabricated from pattern]
• Skilled steps performed: [Positioning technique, molding, edge finishing and flaring, padding placement, strap placement with rationale]
• Modifications during fabrication: [Modifications made and clinical reasoning]

Fit Assessment and Safety Checks

• Trial wear duration in clinic: [Approximate minutes]
• Skin inspection post-trial: [Findings at pressure points and bony prominences: no redness / blanching resolved / persistent erythema / pressure area identified] (For darker skin tones, document alternative assessment such as temperature change or tenderness.)
• Neurovascular status post-fit: [color / temperature / capillary refill / swelling change / sensation / strap tension tolerance] (Include when indicated by orthosis type or compression risk.)
• Objective fit checks: [Landmark clearance / no strap constriction / no edge impingement / adequate suspension / proper alignment]
• Adjustments made: [trimmed edges / flared borders / added padding / repositioned straps] – Re-check results: [Updated findings after adjustment]
• Adverse findings and actions: [If present: stopped wear / modified orthosis / contacted ordering clinician] – Urgent symptom instructions given: [Document instructions provided]

(If skin check or neurovascular status not assessed, document "Not assessed" with reason or "Unable to assess" with constraints and mitigation taken.)

Training Provided

• Donning/doffing: [Method taught] – Assistance level achieved: [independent / supervision / minimal assist / moderate assist / maximal assist] – Return demonstration by: [patient / caregiver] [performed successfully / required additional cueing]
• Wear-during-function training: [Task-specific use, activity restrictions reinforced] (Include only if applicable.)
• Interface and care instructions: [Stockinette or liner use, clothing compatibility, cleaning and drying, heat precautions, strap care, do-not-modify guidance]
• Skin monitoring education: Look for [pressure areas, redness persisting beyond 15–20 minutes after removal, blisters, numbness or tingling, increased swelling, color change]; Actions: [stop wear, contact clinic, criteria for urgent care]
• Teach-back verification: [Patient/caregiver verbalized in own words: what to watch for, when to remove, when to contact clinic, and wear schedule]

Wear Schedule and Precautions

• Wear schedule: [continuous / nighttime only / activity-specific / intermittent with specific timing]
• Break-in schedule: [Progressive wear duration if applicable]
• Removal rules: [e.g., remove for hygiene only / remove every X hours for skin inspection]
• Activity restrictions: [lifting limits / gripping restrictions / weight-bearing status]
• Protocol-critical restriction: [Single most critical restriction stated clearly] (Include only if following post-op or tendon protocol.)
• Heat precautions: [Avoid heat sources, direct sunlight, hot water, car dashboard]
• Stop-and-call triggers: [increased pain / numbness or tingling / swelling increase / color change / skin breakdown / persistent redness beyond 15–20 minutes / device cracking or warping]

Functional Goals Supported

• [Goal 1: specific near-term protection, participation, or prevention target with measurable criterion when possible]
• [Goal 2] (Include only if applicable.)
• [Goal 3] (Include only if applicable; reference plan-of-care goal IDs if established.)

Response to Intervention

• Tolerance: [Pain level, fatigue, skin response during fabrication, fitting, and training]
• Immediate outcomes: [Pain change, comfort rating, task performance with orthosis]
• Engagement and barriers: [Engagement level: high / moderate / low]; [Barriers if present: anxiety / cognitive factors / language barrier] – [Interpreter used: yes / no / not needed]

(If tolerance or response not assessed, document "Not assessed" with reason.)

Plan and Follow-Up

• Follow-up timeframe: [Re-check or adjustment date or interval]
• Planned modifications or wear progression: [Details]
• Home program (orthosis-related): [Exercises allowed in versus out of orthosis, precautions] (Include only if applicable.)
• Communication with surgeon/ordering clinician: [Topics to communicate and method] (Include only if indicated.)

Time and Units

(Include this section only if billing is captured in the clinical note; omit if billing is recorded separately.)

• Total timed treatment minutes: [Minutes]
• Codes billed or anticipated: [CPT codes with units, HCPCS/L-codes if applicable]

Clinician Signature: [Name, credentials] Date/Time Signed: [Date and time]