What information needs to be included in disability paperwork for a patient with neuropathy?

Disability Paperwork for Neuropathy: Essential Documentation Requirements

Disability paperwork for a patient with neuropathy must comprehensively document functional impairment, objective clinical findings, and impact on activities of daily living, as these are the critical elements that determine disability status rather than diagnosis alone.

Core Clinical Documentation Required

Detailed Symptom Assessment

• Document specific sensory symptoms including numbness, tingling, burning sensations, and pain intensity using a numerical rating scale (0-10), noting whether symptoms follow a distal symmetric "stocking and glove" distribution 1, 2, 3
• Record temporal patterns such as nocturnal exacerbation of symptoms, which is characteristic of diabetic neuropathy 2
• Describe both positive and negative sensory symptoms: spontaneous pain (continuous or intermittent), pain evoked by daily activities (allodynia), and abnormal sensations like paresthesias and dysesthesias 4
• Document motor symptoms including any weakness, muscle atrophy, balance problems, falls, or knee buckling that indicate significant proprioceptive loss 5, 4

Objective Physical Examination Findings

• Small-fiber function testing results: pinprick sensation and temperature perception 1, 2
• Large-fiber function testing results: vibration perception using 128-Hz tuning fork and assessment of ankle reflexes 1, 2
• 10-g monofilament testing results at multiple sites on each foot, as this identifies loss of protective sensation (LOPS) and ulceration risk 1, 2
• Document foot deformities including claw toes, hammer toes, bony prominences, and limited joint mobility 1
• Skin examination findings: presence of calluses, ulcers, erythema, warmth, color changes, or evidence of increased pressure 1, 5

Functional Impact and Disability Assessment

• Quantify impact on activities of daily living: difficulty with fine motor tasks (buttoning clothes, writing), walking, standing, maintaining balance 5, 4
• Document fall history and frequency, as this demonstrates significant proprioceptive deficit requiring intervention 5
• Describe limitations in work capacity: inability to stand for prolonged periods, difficulty with repetitive tasks, need for frequent position changes 4, 6
• Record need for assistive devices such as canes, walkers, or orthotic footwear 1
• Document social isolation or reduced access to healthcare due to mobility limitations 1

Laboratory and Diagnostic Evidence

Essential Laboratory Results

• Fasting blood glucose and HbA1c levels to document glycemic control and diabetes severity 1, 5, 2
• Vitamin B12 level with methylmalonic acid and homocysteine to identify reversible nutritional causes 5, 7, 3
• Complete blood count and comprehensive metabolic profile 2, 3
• Thyroid function tests (TSH) 2, 7, 3
• Serum protein electrophoresis if monoclonal gammopathy is suspected 3

Electrodiagnostic Studies (When Performed)

• Include nerve conduction study results showing axonal versus demyelinating patterns, though these are rarely needed for typical diabetic neuropathy 1, 2, 3
• Document electromyography findings if performed to differentiate generalized neuropathy from entrapment syndromes 1, 2

Risk Stratification and Prognosis

IWGDF Risk Classification

Assign the patient to an IWGDF risk category to demonstrate severity and need for ongoing care 1:

• Category 0: No peripheral neuropathy
• Category 1: Peripheral neuropathy alone
• Category 2: Peripheral neuropathy with peripheral artery disease and/or foot deformity
• Category 3: Peripheral neuropathy with history of foot ulcer or lower-extremity amputation

Autonomic Neuropathy Assessment

• Document autonomic symptoms including orthostatic hypotension, resting tachycardia, constipation, diarrhea, urinary retention, erectile dysfunction, and abnormal sweating patterns 1, 2
• Include cardiovascular autonomic testing results such as heart rate variability testing and postural blood pressure measurements if performed 1

Treatment History and Response

Current and Past Treatments

• List all medications tried for neuropathic pain including pregabalin, duloxetine, gabapentin, tricyclic antidepressants, with dosages and duration 1, 5, 7
• Document treatment response or lack thereof, including side effects that limited use 5, 7
• Record glycemic control efforts and whether optimization has slowed progression 1, 7
• Note physical therapy participation and outcomes, particularly for balance training and fall prevention 5

Specialist Consultations

• Document referrals to podiatry, wound care, neurology, or pain management and their recommendations 1, 5, 2
• Include multidisciplinary team involvement for patients with foot ulcers or high-risk feet 1

Critical Pitfalls to Avoid

Do not rely solely on symptoms, as up to 50% of diabetic peripheral neuropathy is asymptomatic, yet patients remain at high risk for complications 1, 2. Always include objective examination findings with specific test results rather than general statements 8.

Avoid vague functional descriptions—instead, provide concrete examples of tasks the patient cannot perform and quantify limitations (e.g., "can stand for only 15 minutes before requiring rest" rather than "has difficulty standing") 4, 9.

Document that neuropathy is a diagnosis of exclusion by noting that other treatable causes (cervical/lumbar disease, vitamin deficiencies, medication toxicity) have been evaluated and excluded 1, 2.

Include photographic documentation of foot deformities or ulcers when present, as visual evidence strengthens disability claims 1.