Foot Care Nurse Course
New Module 7: Patient Assessment & Documentation

Lesson 1: Patient Assessment & Documentation

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Module 7 — Patient Assessment & Documentation
Module 7 of 10 · Single lesson module
Module 7

Patient Assessment & Documentation

Estimated time: 28 min Clinical Skills + Documentation
Learning Objectives

By the end of this lesson, the learner will be able to:

  1. Conduct a structured foot assessment in the standard sequence: history, visual inspection, sensory testing, circulatory evaluation.
  2. Apply appropriate assessment techniques (IWGDF 9-point monofilament, tuning fork, pulse palpation, capillary refill) and interpret results.
  3. Map common foot conditions to the assessment findings that confirm or rule them out.
  4. Document a foot care visit using either SOAP or narrative format, with content that meets clinical, billing, and accreditation standards.
  5. Communicate findings clearly to patients, families, and referring providers — including escalation when findings warrant it.

A foot care visit is more than a treatment — it's an assessment opportunity. Many of the most consequential clinical decisions in foot care nursing (refer or treat, escalate or routine, this visit interval or that one) come from what you find during the assessment, not from the procedure itself. This module covers the structured assessment workflow, condition-specific findings, and the documentation standards that protect both your patient and your practice.

Why Structured Assessment Matters

What good assessment achieves
Early detection Most foot complications start as small findings — a faint pulse, a missed monofilament site, a faintly fissured heel. Structured assessment catches them before they become ulcers, infections, or amputations.
Risk stratification IWGDF risk category drives nearly every downstream decision: visit frequency, scope of intervention, escalation thresholds, patient education emphasis.
Defensibility Documented assessments are the legal record of clinical reasoning. If a complication develops weeks later, your assessment notes are what demonstrate appropriate care.

The Standard Assessment Sequence

The assessment follows a deliberate order: history first (what to look for), then visual inspection (what's present), then sensory testing (what the patient can feel), then circulatory evaluation (what's perfusing). Each step informs the next.

The four-step foot assessment workflow
History → Visual → Sensory → Circulatory · in this order, every visit
Step 1
History
Risk factors, symptoms, medications, prior foot complications
Step 2
Visual
Skin, nails, structure, all surfaces — top, bottom, between toes
Step 3
Sensory
IWGDF 9-point monofilament, tuning fork, pinprick if indicated
Step 4
Circulatory
Pulses, capillary refill, temperature, skin color
Step 1: Patient History & Risk Factors Establishes the lens through which everything else is viewed

The history shapes what you look for and how you interpret what you find. A faint dorsalis pedis pulse means something different in a 30-year-old marathon runner than in a 75-year-old smoker with claudication. Get the history before you put your hands on the foot.

What to ask and document
  • Diabetes status and duration; recent A1C if available
  • Vascular history: known PAD, claudication, prior vascular workup or interventions
  • Neuropathy: numbness, burning, tingling, "pins and needles," nighttime pain
  • Foot pain: location, character, what triggers and relieves it
  • Prior foot complications: ulcers, amputations, infections, surgeries
  • Mobility: ambulation distance, gait aids, falls history
  • Footwear: typical shoes, fit, recent changes
  • Medications relevant to feet: anticoagulants, immunosuppressants, chronic steroids
  • Smoking status and history (significant PAD risk factor)
  • Self-care capacity: can the patient inspect, wash, and reach their own feet?
Step 2: Visual Inspection All surfaces, both feet, every visit

Inspect dorsum, plantar surface, between toes, and heels. Patients are often unable or unwilling to look at the bottoms of their feet, so this is your job. Compare left to right — asymmetry is a finding.

What to inspect and document
  • Skin color: redness, pallor, cyanosis, hyperpigmentation, dependent rubor
  • Skin integrity: cuts, blisters, fissures, ulcers, maceration, scaling
  • Calluses and corns: location, size, sub-callus changes (refer to Module 5 Lesson 2)
  • Nails: thickness, color, ridges, ingrown edges, fungal changes, dystrophy
  • Interdigital spaces: peeling, scaling, maceration (tinea pedis)
  • Structural deformities: bunions, hammer toes, claw toes, Charcot deformity
  • Edema: pitting, non-pitting, unilateral vs bilateral
  • Hair distribution: loss may suggest PAD
Step 3: Sensory Testing Documents loss of protective sensation (LOPS)

Sensory testing — particularly with the 10g Semmes-Weinstein monofilament — is the standard for documenting LOPS. A patient with LOPS is at substantially elevated risk for ulceration and falls into IWGDF Risk 1 or higher, with all the downstream implications for visit frequency and intervention threshold.

Sensory testing methods
  • IWGDF 9-point monofilament exam: 10g monofilament at 9 plantar sites bilaterally (per Module 2 Lesson 4)
  • 128 Hz tuning fork at the dorsum of the great toe (vibration sense)
  • Pinprick or temperature testing as supplementary indicators
  • Patient self-report of numbness, burning, or paresthesia
  • Document number of sites failed and laterality
Loss of Protective Sensation = clinical inflection point

A patient who fails monofilament testing at any of the IWGDF 9 sites has loss of protective sensation. This finding alone moves a diabetic patient from Risk 0 to Risk 1, changes visit frequency, and triggers specific patient education emphasis (drainage and odor as warning signs because pain may be absent — see Module 6). LOPS findings need to be explicitly documented.

Step 4: Circulatory Assessment The decision point for compression, warm soaks, and many interventions

Circulatory assessment matters because it changes what's safe to do. PAD changes the entire intervention plan — compression is contraindicated without ABI, warm soaks become risky, and infection progresses faster with compromised perfusion.

Circulatory assessment methods
  • Palpate dorsalis pedis pulse (top of foot, lateral to extensor hallucis longus tendon)
  • Palpate posterior tibial pulse (behind medial malleolus)
  • Grade pulses: 0 (absent), 1+ (faint), 2+ (normal), 3+ (full), 4+ (bounding)
  • Capillary refill: press toenail or pad, release; normal ≤2 seconds
  • Skin temperature (compare bilaterally and to lower leg)
  • Skin color: pallor on elevation, dependent rubor on lowering — both suggest PAD
  • Hair distribution and skin atrophy (chronic PAD findings)
If pulses are weak or absent: refer for ABI, do NOT apply compression

Weak or absent pedal pulses raise concern for PAD. The next step is referral for vascular workup including ankle-brachial index (ABI) — not compression therapy. Applying compression to a foot with compromised arterial inflow can worsen perfusion and cause limb-threatening ischemia. This is one of the most consequential safety principles in foot care nursing.

Common Conditions and Their Assessment Findings

Condition
Symptoms / Findings
Confirmatory assessment
Diabetic peripheral neuropathy
Numbness, burning, tingling, "pins and needles," often nighttime worsening; may be asymptomatic
IWGDF 9-point monofilament (failure at any site = LOPS); 128 Hz tuning fork; document laterality and severity
Peripheral arterial disease (PAD)
Cold feet, claudication, slow wound healing, hair loss, atrophic skin, dependent rubor
Palpation of dorsalis pedis and posterior tibial pulses; capillary refill; refer for ABI if pulses weak/absent
Tinea pedis
Itching, peeling, scaling, maceration — typically interdigital, often 4th–5th web space
Visual inspection of all interdigital spaces; if uncertain, KOH preparation by provider
Onychomycosis
Thick, yellow-brown, brittle, dystrophic nails; often slowly progressive
Visual inspection; nail clipping for lab confirmation by provider before systemic therapy
Plantar fasciitis
Heel pain, worst with first steps in morning, eases with movement, returns after rest
Palpation of medial calcaneal tubercle reproduces pain; classic history is highly suggestive
Onychocryptosis (ingrown nail)
Pain, redness, possible drainage at lateral nail fold; nail edge curving into skin
Visual inspection; Heifetz staging for severity (Module 3 Lesson 4)
Charcot neuroarthropathy
Warm, red, swollen foot in patient with neuropathy; often misdiagnosed as cellulitis early
Temperature differential between feet; URGENT referral — this is a limb-threatening diagnosis

Documentation: SOAP and Narrative Templates

Documentation serves clinical continuity, billing/coding accuracy, and legal defensibility. The two most common formats are SOAP (Subjective, Objective, Assessment, Plan) and narrative. SOAP is structured and works well for routine visits; narrative is more flexible for complex situations. Either works — what matters is consistency and completeness.

SOAP note — sample foot care visit
Routine visit, established diabetic patient with neuropathy
S — Subjective
65 y/o male w/ T2DM (15 yrs) presents for routine 8-week foot care. Reports occasional numbness in toes bilaterally; denies new pain, drainage, or skin breaks. No recent footwear changes. Continues home foot inspection daily; uses urea 20% emollient as prescribed.
O — Objective
BILATERAL FEET
Skin: intact, no open wounds, mild xerosis on heels.
Nails: great toenails moderately thickened, no acute paronychia.
Interdigital: dry, no scaling.
Sensory: IWGDF 9-pt monofilament — failed at 3/9 sites bilaterally (plantar 1st MTH, plantar 5th MTH, plantar hallux). Tuning fork: diminished vibration at hallux bilaterally.
Circulatory: dorsalis pedis 2+ bilaterally, posterior tibial 2+ bilaterally. Cap refill ≤2 sec. Skin temp WNL, no dependent rubor.
IWGDF risk category: 1 (LOPS, no PAD, no deformity, no prior ulcer).
A — Assessment
T2DM with confirmed loss of protective sensation; IWGDF Risk 1. Bilateral onychauxis. Mild xerosis. No active infection or ulceration. Stable from prior visit.
P — Plan
Trimmed nails bilaterally per natural contour, lateral corners visible, edges filed (instruments: set #4, autoclaved 03/15, indicator verified).
Reinforced education: daily foot inspection with mirror, drainage/odor as warning signs (pain may be absent), urea 20% emollient daily (not between toes).
Recommended footwear review at next visit.
Follow-up: 8 weeks. Patient instructed to call sooner for any skin break, drainage, redness, or new pain.
Coordination: copy of note to PCP per established practice.
Narrative note — same visit
Same content, prose format — useful when SOAP feels constraining
Narrative
65-year-old male with type 2 diabetes (15 years) presented for routine 8-week foot care. Patient reports occasional numbness in toes bilaterally, denies new pain, drainage, or skin breaks. Continues daily home foot inspection and uses urea 20% emollient as prescribed.

Bilateral foot examination: skin intact with mild heel xerosis, no open wounds. Great toenails moderately thickened bilaterally, no acute paronychia. Interdigital spaces dry. Sensory examination using IWGDF 9-point monofilament protocol revealed failure at 3 of 9 sites bilaterally (plantar 1st MTH, plantar 5th MTH, plantar hallux), confirming loss of protective sensation. Tuning fork at hallux showed diminished vibration sense bilaterally. Circulatory assessment: dorsalis pedis and posterior tibial pulses 2+ bilaterally, capillary refill within 2 seconds, skin temperature within normal limits, no dependent rubor. IWGDF risk category: 1 (LOPS, no PAD, no deformity, no prior ulcer).

Findings consistent with stable diabetic peripheral neuropathy, IWGDF Risk 1, with bilateral onychauxis and mild xerosis. No active infection or ulceration; status stable from prior visit.

Trimmed nails bilaterally following natural contour with lateral corners visible; edges filed. Instruments: set #4, autoclaved 03/15, chemical indicator verified. Reinforced patient education on daily foot inspection with mirror, recognition of drainage and odor as warning signs given LOPS, daily urea 20% emollient (not between toes). Recommended footwear review at next visit. Follow-up scheduled in 8 weeks; patient instructed to call sooner for any skin break, drainage, redness, or new pain. Note copied to PCP per established practice.
What every foot care note should contain

Whether SOAP or narrative, every note should include: 1) patient identifiers and visit type; 2) relevant history and any reported symptoms; 3) structured findings from all four assessment domains (history, visual, sensory, circulatory); 4) IWGDF risk category if applicable; 5) instruments used and reprocessing reference; 6) interventions performed; 7) patient education provided; 8) follow-up plan and contingency instructions; 9) coordination with referring or primary care providers.

Communicating Findings

Communication framework
Three audiences for the same assessment
To the patient

Plain language; explain what you found and what it means. Use the "teach back" method — ask the patient to repeat back the key takeaway and what they will do at home.

To the family / caregiver

With the patient's consent. Especially important for cognitive impairment, limited mobility, or when the caregiver does the daily inspection. Repeat the same key points with caregiver-appropriate framing.

To the PCP / specialist

SBAR or structured summary: Situation, Background, Assessment, Recommendation. Include specific findings with measurements, your concern level, and what you're requesting (review, referral, urgent evaluation).

For escalation

Be explicit about urgency. "I need a same-day evaluation for this finding" is more useful than "the patient might want to follow up." Document the communication: who, when, what was said, what response.

SBAR for foot-care escalation

Situation: "I'm calling about Mr. Garcia, your patient with diabetes, who I just saw for routine foot care." Background: "He has 15-year T2DM with peripheral neuropathy, IWGDF Risk 1, no prior foot complications." Assessment: "I found a 1.5cm draining ulcer at the plantar 1st MTH with surrounding erythema; he reports no pain. Pedal pulses present, capillary refill 2 seconds." Recommendation: "I'm requesting urgent evaluation today — can he be seen this afternoon, or should I direct him to urgent care?"

Case Studies

Case Study 1
Detecting early neuropathy in a diabetic patient
Patient58-year-old man with type 2 diabetes (8 years), no prior foot complications.
IssueReports occasional numbness in toes; denies pain. Routine foot care visit.
Assessment findings and plan
  • History: numbness in toes; no pain, no claudication, no prior ulcer; smoker (history of tobacco use 20 pack-years)
  • Visual: skin intact, mild xerosis, nails normal, no interdigital findings
  • Sensory: IWGDF 9-pt monofilament failed at 3/9 sites bilaterally; diminished vibration at hallux bilaterally — confirms LOPS
  • Circulatory: dorsalis pedis and posterior tibial 2+ bilaterally, cap refill ≤2 sec, no PAD findings
  • IWGDF risk category: 1 (LOPS only; no PAD, no deformity, no ulcer history)
  • Plan: routine foot care; reinforced patient education with emphasis on drainage/odor since pain may be absent; daily inspection; follow-up at 8 weeks; coordinated with PCP including smoking cessation discussion
Case Study 2
Suspected PAD in an elderly patient — what NOT to do
Patient72-year-old man, history of smoking (40 pack-years), reports leg pain when walking that improves with rest.
IssueCold feet bilaterally; small cuts on toes "take forever to heal."
Assessment findings and plan
  • History: claudication (calf pain at ~100 ft, resolves with rest); cold feet; slow wound healing
  • Visual: hair loss on dorsum bilaterally; pale, cool toes; dependent rubor on lowering; atrophic skin
  • Sensory: monofilament intact at all sites; no LOPS
  • Circulatory: dorsalis pedis 1+ right, absent left; posterior tibial 1+ bilaterally; capillary refill 5 sec bilaterally — significant findings
  • Plan: refer for vascular evaluation including ABI — do NOT apply compression therapy without confirmed adequate arterial inflow; refer for smoking cessation; modify foot care to conservative approach with no aggressive callus reduction or skin-breaking interventions; document findings clearly to PCP and request expedited vascular consult
Critical correction: compression is contraindicated in suspected PAD without ABI

Some older sources recommend "compression therapy" for cold feet in patients like Case Study 2. This is a serious clinical error — applying compression to a foot with compromised arterial inflow can worsen perfusion and cause limb-threatening ischemia. The correct intervention for suspected PAD is vascular workup with ABI first; compression decisions are made only after ABI confirms adequate inflow. This is a frequently-tested principle and a real-world safety issue. Module 3 Lesson 5 covers it in detail.

Module Summary
What every foot care nurse should master
  • Conduct the four-step assessment in order: history, visual, sensory, circulatory — every visit, every patient
  • Use the IWGDF 9-point monofilament exam as your standard sensory test; document number of sites failed and laterality
  • Check both pedal pulses (dorsalis pedis, posterior tibial) and capillary refill (≤2 seconds is normal)
  • Weak/absent pulses → refer for ABI; never apply compression to a suspected-PAD foot without ABI confirmation
  • Document IWGDF risk category, instruments used, interventions, education, and follow-up plan in every note
  • Use SBAR for escalation communication; be explicit about urgency level when you call

Ready to check your understanding? Take the quick knowledge check for this module.

✓ End of Module 7
You've completed Patient Assessment & Documentation

Next up: Module 8 — Patient Education & Follow-Up Care.

Educational Disclaimer

The information on this website and any communication with RNscrub Foot Care is provided for educational and informational purposes only. It is not a substitute for medical advice, diagnosis, or treatment. Patients are always encouraged to consult with their primary care provider or appropriate specialist for individual clinical decisions.

References

  1. International Working Group on the Diabetic Foot (IWGDF). IWGDF Guidelines on the Prevention and Management of Diabetes-Related Foot Disease. 2023.
  2. Boulton AJM, Armstrong DG, Albert SF, et al. Comprehensive Foot Examination and Risk Assessment: A Report of the Task Force of the Foot Care Interest Group of the American Diabetes Association. Diabetes Care. 2008;31(8):1679–1685.
  3. American Diabetes Association. Standards of Care in Diabetes — Foot Care. Diabetes Care. 2024;47(Suppl 1).
  4. Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases. European Heart Journal. 2018;39(9):763–816.
  5. Society for Vascular Surgery. Practice Guidelines for Atherosclerotic Occlusive Disease of the Lower Extremities. (Current version.)
  6. Wound, Ostomy and Continence Nurses Society (WOCN). Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. 2012 (and subsequent updates).
  7. The Joint Commission. Standards for Documentation in Healthcare Records.
  8. Institute for Healthcare Improvement. SBAR Communication Tool. (Standard handoff communication framework.)
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