What are the key components to document in a normal diabetic foot exam?

Documentation of Normal Diabetic Foot Examination

A comprehensive diabetic foot examination should be documented including inspection, assessment of foot pulses, and testing for loss of protective sensation with the 10-g monofilament and at least one additional neurological test, with all findings noted as normal. 1

Key Components to Document

History

• Document absence of previous foot problems
• Note absence of symptoms of neuropathy (no pain, burning, numbness)
• Document absence of symptoms of vascular disease (no leg fatigue or claudication)
• Note absence of risk factors (smoking status, glycemic control) 2, 1

Skin Inspection

• Document normal skin integrity
• Note absence of calluses, corns, or preulcerative lesions
• Document normal skin color and temperature
• Note absence of edema
• Document normal appearance of interdigital spaces 2, 1

Neurological Assessment

1. 10-g Monofilament Testing

   • Document testing at specific sites (typically plantar surface of hallux, 1st, 3rd, and 5th metatarsal heads)
   • Note normal sensation (patient correctly identified 2 out of 3 applications at each site)
   • Document "No Loss of Protective Sensation (LOPS)" 2, 1

2. Additional Neurological Test (at least one of the following):

   • Vibration sensation using 128-Hz tuning fork: document normal perception
   • Pinprick sensation: document normal discrimination
   • Ankle reflexes: document normal reflexes
   • Tactile sensation: document normal perception 2

Vascular Assessment

• Document palpable dorsalis pedis pulses bilaterally
• Document palpable posterior tibial pulses bilaterally
• Note normal capillary refill time (<3 seconds)
• Document absence of dependent rubor or pallor on elevation 2, 1

Musculoskeletal Assessment

• Document absence of foot deformities (no bunions, hammertoes, or Charcot joint)
• Note absence of bony prominences
• Document normal joint mobility 2, 1

Footwear Assessment

• Document appropriate footwear
• Note absence of pressure points or irritation from shoes 2, 1

Risk Classification and Plan

• Document risk category: "Very Low Risk" (no LOPS, no PAD, no deformity, no history of ulceration or amputation) 2, 1
• Document follow-up recommendation: "Annual comprehensive diabetic foot examination" 1
• Note foot care education provided to patient 2, 1

Documentation Example

Diabetic Foot Examination:
History: No previous foot ulcers or amputations. No symptoms of neuropathy or vascular disease.
Skin: Normal integrity, color, and temperature. No calluses, corns, or lesions. Interdigital spaces clear.
Neurological: 10-g monofilament testing normal at all sites bilaterally. Vibration sensation with 128-Hz tuning fork normal bilaterally. No LOPS.
Vascular: Dorsalis pedis and posterior tibial pulses 2+ bilaterally. Normal capillary refill.
Musculoskeletal: No foot deformities or bony prominences. Normal joint mobility.
Footwear: Appropriate, no areas of excessive wear or pressure points.
Risk Assessment: Very Low Risk
Plan: Annual comprehensive diabetic foot examination. Foot care education provided.

Common Pitfalls to Avoid

• Failing to document all components of the examination, even when normal 1
• Not including at least one additional neurological test beyond monofilament testing 2
• Omitting risk classification and follow-up recommendations 2, 1
• Neglecting to document patient education provided 2, 1

Remember that proper documentation of a normal examination establishes a baseline for future comparisons and helps identify changes that may indicate early complications, potentially preventing serious outcomes like ulceration and amputation 2.