Splint, Cast, or Immobilization Procedure Note

Date/Time of Application: [Date and time of immobilization application]

Patient Name: [Full legal name]

Date of Birth: [DOB]

Anatomic Location and Laterality: [Explicit laterality and anatomic region] (Laterality must always be stated clearly.)

Indication: [Working or confirmed diagnosis prompting immobilization]

Clinical Context

[Brief rationale for immobilization] (Summarize in 2–4 sentences: mechanism and timing of injury; imaging status with key finding if reviewed, or state pending/deferred with rationale; soft tissue status including swelling and skin integrity; clinical reasoning for device choice. Do not repeat full HPI.)

Consent: [verbal / written] — [Key risks discussed] — [Patient agreed to proceed] (Include only if required by policy or if formal consent was obtained.)

Pre-Procedure Examination

(Document specific baseline neurovascular findings. Do not use acronyms like "NVI" without specifying components examined.)

Before: Perfusion: [Capillary refill time, skin color/temperature, distal pulse quality]. Sensation: [Light touch in named nerve distributions, e.g., median/ulnar/radial or superficial peroneal/deep peroneal/tibial]. Motor: [Named movements, e.g., thumb IP extension, finger abduction, wrist extension; ankle dorsiflexion, great toe extension]. Compartments: [soft / tense / not assessed]. Limitations: [What limited the exam, what was assessed, and plan for reassessment] (Include only if applicable.)

Procedure Details

Device: [splint / cast / brace / boot] — [Specific design, e.g., thumb spica splint, sugar-tong splint, short leg cast, CAM boot] — Joints immobilized: [joints]; Joints left free: [joints]

Position: [Limb/joint position with degrees when clinically important]

Materials: [Padding type and coverage; extra padding over bony prominences if applied; casting material (plaster/fiberglass); modifications (bivalved, windowed, sling provided)] (For prefabricated devices: size and fit confirmation.)

Technique: [Concise description of key steps] (Note whether reduction was performed prior and reference separate reduction note if applicable; confirm device molded to contours, edges padded, fit confirmed.)

Personnel: [Who applied the device and who assessed fit/neurovascular status] (If delegated: "Applied by [staff role] under my direction; I personally assessed fit and neurovascular status before and after application.")

Post-Procedure Assessment

Outcome: [Adequate stabilization achieved / inadequate — actions taken]; [Patient comfort and tolerance]; [Immediate complications: none / describe and corrective actions taken]

After: Perfusion: [Capillary refill time, skin color/temperature, distal pulse quality]. Sensation: [Light touch in named distributions]. Motor: [Named movements]. Compartments: [soft / tense / not assessed]. Comparison to baseline: [unchanged / improved / worsened] (If worsened, document corrective action and outcome.)

Instructions and Precautions

Device Care: [Keep dry, do not insert objects inside, elevate as directed, move uninvolved joints/digits] (Include only items actually instructed.)

Activity Restrictions: [non-weight bearing / partial weight bearing / weight bearing as tolerated]; [Work/driving/sports restrictions]; [Assistive devices provided and training completed: crutches / walker / sling]; [Elevation/ice instructions]

Return Precautions: Patient instructed to seek urgent/emergency care if any of the following occur:

• Increasing pain or tightness not relieved by elevation
• Numbness, tingling, color change (pale/blue), or coolness of digits
• Marked swelling distal to the device or inability to move fingers/toes
• Wet, broken, or damaged device
• Fever, foul odor, or drainage suggesting infection

Follow-Up

Referral: [Orthopedics / hand surgery / podiatry / primary care] within [timeframe]. Repeat imaging: [Type and timing if indicated]. Contingency: [Plan if specialist appointment unavailable]

Patient verbalized understanding of instructions and precautions. Written instructions provided. (Note if interpreter or caregiver assisted.)