General Section
SKILLED DOCUMENTATION GUIDELINES — EXPANDED
DiraChart · Clinical Reference · Read-only baseline inherited by all agencies
Body System Reference · 2.25
Touch / Peripheral Sensation
Peripheral sensory function and its consequences for injury and falls. Diagnoses commonly routed here: peripheral neuropathy (diabetic and other), loss of protective sensation, paresthesia and numbness, impaired proprioception, and reduced temperature or pain sensation. The glycemic driver of diabetic neuropathy lives in Endocrine/Metabolic and the Diabetes overlay; the insensate foot wound lives in Wounds; acute or central sensory loss — sudden, with weakness or other deficits — lives in Neurological; sensory-related fall risk is shared with Safety.
Module code | SYS-TOUCH-SENSATION |
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Version | 1.0 · Population: Adult · Authoring level: DiraChart (read-only baseline; agencies may append) |
Used alongside | Endocrine / Metabolic + Diabetes overlay (neuropathy driver) · Wounds (insensate foot ulcer) · Neurological (acute / central) · Safety (injury risk) |
How to use this module This module supplies the peripheral sensory examination — light touch, monofilament testing of the foot, proprioception, temperature and pain sensation — and the skilled language that proves it required a licensed nurse, with the focus on preventing the silent injuries that follow lost protective sensation. The glycemic cause of diabetic neuropathy is documented in Endocrine/Metabolic and the Diabetes overlay; an actual foot wound is documented in Wounds; sudden or central sensory loss is documented in Neurological. Each narrative is a structured example to edit to the actual visit and the patient’s orders — not a phrase to copy. |
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