Use when protective sensation is intact or a chronic deficit is stable and well-compensated. Fill the bracketed blanks with the visit’s actual findings; the clinical findings are not changed — the reasoning a layperson cannot supply is added. The skilled rationale supports the record when it is accurate, individualized, consistent with the plan of care, and tied to the findings, orders, and patient response documented during the actual visit.
Skilled peripheral sensory assessment completed. Light touch [intact/level] and [symmetric], unchanged from baseline. Protective sensation [intact to the 10-gram monofilament at all tested sites / reduced at …], proprioception [intact]; temperature/pain discrimination [intact where tested]. [No] new numbness, tingling, or burning; distribution [described]. Skin [intact] in areas of [any reduced] sensation, no unnoticed injury. The standardized sensory testing against baseline confirms [intact protective sensation / a stable compensated deficit] and continued appropriateness of the protection plan; daily skin and foot inspection and injury and burn prevention reinforced with the patient/caregiver, who [teach-back result] (cross-reference Endocrine/Metabolic, Wounds, Safety).
Short form
Skilled sensory assessment: light touch intact/symmetric; protective sensation [intact to monofilament / reduced at sites]; proprioception intact; no new symptoms; skin intact in reduced-sensation areas. Protection plan appropriate. Foot/skin-check and injury prevention reinforced, teach-back correct.
