The diabetic foot exam (DFE) is a focused physical assessment performed on individuals with diabetes to identify risk factors for serious foot complications. Accurate documentation of this examination supports the goal of preventing severe infection or lower-extremity amputation. A comprehensive record ensures that changes in the patient’s foot health are tracked over time, providing continuity of care across different healthcare providers. Detailed documentation also verifies that necessary preventative measures and education have been administered.
Essential Elements of the Examination Record
The physical findings must be recorded, structured around the three main components: neurological, vascular, and dermatological/musculoskeletal assessments. Documentation must record the specific tests performed and the exact results obtained, moving beyond a simple checklist.
Neurological Assessment
Documentation of neurological status focuses on identifying peripheral neuropathy, particularly the loss of protective sensation (LOPS). The primary method is the 10-gram monofilament test. The record must specify the sites tested (typically the plantar surface of the great toe and the heads of the first, third, and fifth metatarsals) and whether the patient perceived the pressure. Recording LOPS indicates a high risk of injury due to an inability to feel minor trauma.
Documentation must also include the results of at least one other neurological test, such as assessing vibratory perception using a 128-Hz tuning fork on a bony prominence. Alternatively, the record may note the status of ankle reflexes or pinprick sensation. All findings, even if normal, must be explicitly noted.
Vascular Assessment
The vascular documentation focuses on detecting peripheral artery disease (PAD), which impairs wound healing. The record must state the quality of the pedal pulses (dorsalis pedis and posterior tibial arteries), often graded on a scale (e.g., 2+ for normal). Documentation of capillary refill time, noting if it is prolonged (greater than two to three seconds), assesses perfusion status.
If measured, the ankle-brachial index (ABI) result must be included, as it provides an objective measure of arterial blood flow. An ABI value of 0.9 or less strongly suggests PAD. Descriptive vascular observations, such as dependent rubor (redness when the leg is lowered) or pallor on elevation, must also be documented.
Dermatological and Musculoskeletal Findings
Documentation of the skin and structure involves inspecting the entire foot, including the interdigital spaces. The record must detail skin integrity, noting the presence, size, and location of calluses, blisters, fissures, or signs of fungal infection. Existing ulcers must be described precisely, including their location, size, depth, and characteristics of the wound base and surrounding skin.
Musculoskeletal findings focus on structural deformities that create abnormal pressure points, which precede ulceration. The documentation should list specific deformities such as hammertoes, claw toes, bunions, or the “rocker-bottom” shape associated with Charcot neuroarthropathy. Temperature differences or localized warmth, which can signal infection or acute Charcot activity, must also be recorded.
Documenting Risk Stratification and Assessment
The documentation must translate clinical data into a specific, actionable risk category for future ulceration. This systematic risk stratification links the assessment to the prescribed plan of care. The record must explicitly state the risk level based on a recognized classification system, such as the International Working Group on the Diabetic Foot (IWGDF) categories.
The risk level dictates the frequency of future preventative exams and justifies specialized interventions, such as prescribing therapeutic footwear for higher-risk patients.
IWGDF Risk Categories:
- Risk 0 (Very Low Risk): No loss of protective sensation (LOPS) and no peripheral artery disease (PAD).
- Risk 1 (Low Risk): LOPS present but no history of ulceration.
- Risk 2 (Moderate Risk): LOPS and PAD, or LOPS and a foot deformity.
- Risk 3 (High Risk): LOPS or PAD combined with a history of foot ulcer, amputation, or end-stage renal disease.
For patients with an active ulcer, the documentation must also include a grading of the wound itself, using systems like the Wagner Classification. This classification grades ulcers based on depth and the presence of gangrene, communicating the complexity of the required wound management.
Procedural Documentation and Follow-Up Planning
Administrative details are important for legal compliance and smooth transitions of care. The record must include the date and time of the examination, along with the name and professional credentials of the provider. This establishes accountability and verifies the procedure.
To ensure the exam is recognized for billing purposes, documentation requires appropriate medical coding. This involves using specific Current Procedural Terminology (CPT) codes for the comprehensive foot exam and corresponding International Classification of Diseases (ICD-10) codes for underlying conditions (e.g., diabetic neuropathy or a specific foot ulcer). Correct coding confirms the preventative service was rendered and supports medical necessity.
Documentation of patient education is required, confirming the patient was informed of their current risk status, given instructions for daily self-care (including checking their feet), and advised on appropriate footwear. Finally, the documentation must outline the specific follow-up plan, including the date or frequency of the next required diabetic foot exam.