Diabetic Foot Exam Template

Key Takeaways

A diabetic foot exam is a systematic clinical assessment that identifies early signs of neuropathy, vascular disease, and skin breakdown to prevent serious complications like ulcers and amputation.

The exam includes five core assessments: monofilament testing for loss of protective sensation (LOPS), vascular pulse and ankle-brachial index checks, visual skin and nail inspection, foot structure evaluation, and risk stratification into low/moderate/high tiers.

Annual comprehensive foot exams aligned with ADA standards can reduce amputation risk by enabling early detection and timely specialist referral before complications develop.

Practice management software like Pabau helps clinicians structure and store diabetic foot exam findings, automate risk-based recall reminders, and support accurate billing and coding for routine and problem-focused exams.

Download your free diabetic foot exam template

Use the free diabetic foot exam template below to standardize every screening. Download it as a printable PDF, then adapt the fields to your practice and rebuild it as a digital form inside your patient records.

A diabetic foot exam is a structured screening that checks sensation, circulation, and skin integrity to catch problems before they progress to ulcers or amputation. This guide covers what the exam involves, how to perform each assessment step, how to translate findings into a risk tier, and how to document and code the visit correctly.

Why a diabetic foot exam template matters

Undetected diabetic foot complications account for significant morbidity and preventable amputations. Foot amputations may be required in up to 20% of diabetic foot ulcers, many of which could have been prevented through early detection during routine exams.

A structured diabetic foot exam template ensures clinicians systematically assess every patient’s foot health-not just a visual check, but a comprehensive evaluation of sensation, circulation, skin integrity, and structural integrity.

Many primary care practices, diabetes care teams, and podiatry groups lack a standardized workflow for foot exams. Some clinicians miss critical findings, while others over-document and struggle with accurate coding.

A patient management system with a built-in exam template solves both problems-it guides clinicians through the checklist, auto-populates structured findings, and flags abnormal results that require specialist referral. Whether you call it a diabetic foot examination template or a diabetic foot examination form, the goal is the same: a repeatable checklist every clinician follows.

What is a diabetic foot exam?

A diabetic foot exam is a systematic clinical assessment designed to identify early signs of foot complications in patients with diabetes. Foot exams for diabetics, sometimes abbreviated to a DM foot exam, evaluate three primary domains: neurological status (sensation), vascular function (blood flow), and structural or dermatological integrity (skin, nails, deformities).

Because diabetes affects multiple organ systems through shared microvascular and neuropathic pathways, care teams often coordinate this exam alongside other systemic screenings, such as retinal evaluations coded under H35.89.

The American Diabetes Association (ADA) Foot Examination Risk Assessment established evidence-based standards for this assessment. According to CDC clinical guidance, annual foot exams assess pulses, sensation, foot structure and function, and nails-and document findings using a consistent format to support clinical decision-making and accurate billing.

From a compliance perspective, a documented foot exam also demonstrates that your practice meets standards of care for diabetes management. It creates a defensible record should questions arise about whether appropriate screening occurred.

How to use a diabetic foot exam template

A well-designed template guides clinicians through the five core assessment steps. Here is how to implement the exam in practice:

1. Patient history and risk context. Record diabetes duration, prior foot ulcers, amputations, and current symptoms. Note any pain, numbness, or difficulty walking. This context frames the interpretation of exam findings.
2. Visual inspection of skin and nails. Examine both feet systematically. Look for calluses, cracks, fissures, blisters, ulcers, color changes, and signs of infection. Check between toes and the soles. Document any structural deformities (hammertoes, hallux valgus, Charcot foot).
3. Neurological assessment using the 10-gram monofilament test. Press the Semmes-Weinstein monofilament against the skin at five test sites per foot (plantar surface) until the monofilament bends slightly, applying 10 grams of pressure. Ask the patient to report when they feel contact. Loss of sensation at ≥1 site indicates loss of protective sensation (LOPS), a major risk factor for ulceration.
4. Vascular assessment via pulse palpation and dorsalis pedis/posterior tibial pulse evaluation. Palpate for pulses and compare bilateral symmetry. Note whether pulses are present, diminished, or absent. In high-risk patients, consider ordering a toe-brachial index (TBI) or ankle-brachial index (ABI) to quantify arterial insufficiency.
5. Risk stratification and documentation. Assign a risk tier (low/moderate/high/very high) based on exam findings. Document all findings in a structured format-using digital forms allows clinicians to auto-populate key fields and generate consistent, searchable records.

When using AI-powered clinical documentation alongside your exam, you can dictate findings during or immediately after the exam, and the system transcribes and structures them into a note without manual typing.

Who should use this template

A diabetic foot exam template is essential for primary care physicians, family medicine practitioners, and internal medicine doctors managing diabetic patient panels.

Podiatrists and diabetes educators use it as a clinical standard, and nurse practitioners and physician assistants working in diabetes or wound care settings also benefit from the structured approach.

Physical therapy practices and integrated medicine practices that address metabolic health and diabetes prevention increasingly incorporate foot exams into their preventive care protocols. Even in busy urgent care or occupational health settings, a quick-reference template ensures core assessments are completed.

Benefits of a standardized foot exam template

Compliance and risk reduction: A documented foot exam demonstrates adherence to standards of care. It protects your practice in audits and reduces liability exposure by creating a clear record of what was assessed and what was communicated to the patient.

Early detection: Systematic assessment catches neuropathy and vascular disease before they progress to ulcers. Early detection enables timely specialist referral and preventive interventions.

Workflow consistency: A template ensures every clinician performs the same core assessment steps, reducing variability and missed findings. It also streamlines scheduling frequency reminders-systems can flag annual recall dates automatically.

Accurate billing and coding: Structured documentation supports correct billing code and ICD-10 code assignment, reducing claim denials and coding errors.

Risk stratification: from exam findings to action

The diabetic foot exam’s primary goal is to assign patients to risk tiers that guide clinical action. Risk stratification drives referral decisions and determines exam frequency.

• Low risk: Protective sensation intact, normal pulses, no deformities or prior ulcers. Annual exam sufficient.
• Moderate risk: Loss of protective sensation (LOPS) OR diminished pulses. Exam every 6-12 months. Consider podiatry referral for foot care education.
• High risk: LOPS plus vascular disease OR prior ulcer/amputation. Exam every 3 months. Urgent podiatry/vascular referral if new findings.
• Very high risk: Current ulcer, gangrene, or acute Charcot foot. Immediate specialist referral; may require inpatient assessment.

A well-designed template auto-calculates risk tier based on exam findings, removing guesswork and supporting consistent triage.

Documentation, coding, and integration

Routine or preventive foot exams are typically billed under standard evaluation and management (E&M) codes as part of the visit. HCPCS Level II codes G0245, G0246, and G0247 apply to a narrower Medicare scenario: a patient already diagnosed with diabetic sensory neuropathy resulting in loss of protective sensation (LOPS).

G0245 covers the initial evaluation of that patient, G0246 the follow-up evaluation, and G0247 routine foot care-billable only alongside G0245 or G0246 on the same date of service. These are not preventive or screening codes.

Medicare coverage also extends to qualified nurse practitioners and physician assistants, not just physicians, but that’s a coverage rule rather than part of the code definitions themselves.

Accurate documentation supports correct coding regardless of which pathway applies. Building the template into your EHR as a diabetic foot exam dot phrase, or SmartText autotext, speeds charting and keeps the billing code and supporting detail consistent across clinicians.

Common ICD-10 codes for a documented foot exam include:

• E11.9 – Type 2 diabetes mellitus without complications (routine foot exam on a patient with diagnosed diabetes and no active complication)
• E11.42 – Type 2 diabetes mellitus with diabetic polyneuropathy (when neuropathy is the documented finding driving the exam)
• E11.621 – Type 2 diabetes with foot ulcer (when ulcer is present; links the exam to the diagnosis). Pair this with a companion L97.4- or L97.5- code specifying the ulcer’s site and laterality, or the claim will deny.

Diabetes care rarely stops at the foot exam. On the same visit day, a patient might also be billed for insulin administration under J1815 or medical nutrition therapy under 97802, so check for NCCI edits before submitting multiple codes on one claim.

Storing exam templates in HIPAA-compliant digital systems ensures that findings are secure, searchable, and easily retrieved for audits or follow-up care. Compliance management tools can flag exams that are overdue and auto-trigger recall reminders to patients.

Conclusion

A standardized diabetic foot exam template transforms foot assessment from an ad-hoc screening into a systematic, replicable clinical process. It reduces amputation risk by catching complications early, and it ensures your practice keeps consistent documentation and supports accurate coding.

Download the template above, implement it in your practice workflow, and schedule a demo to see how Pabau’s digital forms integrate diabetic foot exams into your patient record system.

Continue your research

Need to store exams in a searchable clinical record? Client record system maintains all foot exam templates and historical findings in one secure location, so you can compare results year over year.

Want to automate annual recall reminders? Automated workflows can trigger SMS or email reminders when a patient’s annual exam is due, increasing compliance.

Looking to streamline documentation during the exam? Cloud-based EHR systems designed for private practice let clinicians access templates on tablet or mobile device, record findings in real time, and sync instantly across locations.

Frequently asked questions