Diabetic foot risk and review recalls

Assessing

On a clinical note, press Diabetic foot risk. For each foot:

• 10 g monofilament at the usual 10 sites: tap a site once for felt, again for not felt (or All felt). Fewer than 8 of 10 felt counts as loss of protective sensation.
• Vibration, and the dorsalis pedis and posterior tibial pulses. Absent vibration counts as neuropathy; neither pulse palpable on a foot (or another sign you tick, such as an ABPI below 0.9) counts as limb ischaemia.
• Deformity and callus.

Then the history (previous ulceration or amputation, renal replacement therapy) and any active problem (ulceration, spreading infection, critical limb ischaemia, gangrene, suspected acute Charcot, or an unexplained hot, red, swollen foot).

The level

Hally suggests a level following NICE guideline NG19, with what led to it:

• Low: no risk factors, apart from callus on its own.
• Moderate: deformity, or neuropathy, or non-critical limb ischaemia.
• High: previous ulceration or amputation, renal replacement therapy, neuropathy and ischaemia together, or either of them with callus or deformity.
• Active: any active problem.

It's clinical decision support: it can't see the whole patient. Confirm the level yourself; to choose a different one, say why. NICE's review interval and next step show for the level you choose (paraphrased; the guideline is the reference).

The recall

Choose when to see them again: NICE's interval is offered first (12 months for low risk; 3 to 6 months for moderate; 1 to 2 months for high, or 1 to 2 weeks with immediate concern). Once the note is signed, Foot review due shows on Today and on the patient's record from a fortnight before. If the note is linked to an appointment and Send them a reminder when it's due is ticked, the patient gets an email (or a text, if they've agreed to texts) at 10am on the day, unless they've booked from a fortnight before. It never names their condition. Change its wording in Settings → Messages (Foot review due).