Touch Peripheral Sensation

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DiraChart Clinical Reference
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1. Purpose and clinical relevance

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16. Weak vs. strong documentation

Paired entries for this system. The left column is denial-bait; the right column is the same clinical picture written so a reviewer can see why a nurse was required.

Weak — does not survive

Why it fails

Strong — defensible

“No numbness.”

No testing, no protective-sensation status, no skilled assessment — a layperson observation.

“Protective sensation intact to 10-g monofilament at all plantar sites; light touch symmetric; no new deficit from baseline.”

“Sensation okay.”

Qualitative, no method, no comparison.

“Light touch intact distal-to-proximal bilaterally; proprioception intact at great toes; unchanged from baseline.”

“Feet numb.”

No site, no risk, no action.

“Protective sensation absent at great toes and forefoot per monofilament, progressed from baseline; foot-protection intensified, podiatry referral requested.”

“Sore on foot.”

No link to sensation, no offloading, no notification.

“1 cm painless plantar ulcer in an insensate foot the patient could not feel; offloaded, MD notified, wound care ordered (see Wounds).”

“Educated on foot care.”

No content, no learner response.

“Daily foot inspection with mirror and burn prevention taught; patient return-demonstrated a correct foot check; reporting of new lesions reinforced.”

“Some tingling.”

No distribution, no change, no plan.

“New burning paresthesia in a stocking distribution, progressed from baseline, affecting sleep; MD notified, neuropathic-pain order received.”

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