Touch Peripheral Sensation

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Trace DC70-10

DiraChart Clinical Reference
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1. Purpose and clinical relevance

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9. Weak vs. strong documentation

Weak — does not survive

Why it fails

Strong — defensible

“Neuropathy, no change.”

No sensory exam, no protective management, no skin/foot inspection, no rationale.

The neuropathy model note in §3: the sensory distribution and protective-sensation status, the feet/skin inspection, the protective management, and the reason skilled management was required.

“Numbness in feet.”

No distribution, no safety consequence, no protection.

“Reduced protective sensation, stocking distribution, both feet (diminished monofilament); feet intact; protective footwear/offloading in place; no injury.”

“Sensation decreased on left.”

For a new change, no escalation or associated-sign screen.

The acute-change model note in §4: the pattern/level, the associated weakness/bowel-bladder screen, the urgent notification, and the pathway activated.

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