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Identifying and documenting sensory involvement

Data Collection - As the health care practitioner performs the examination of somatosensation, a variety of data will be collected for each sensory modality as described below.

Distribution of sensory involvement - The health care practitioner may begin by testing general body areas. If a deficit is found, systematic testing is required to delineate the boundaries of the deficit:

  • A skin pencil can be used to mark the area of involvement.
  • A body chart is often used to map out areas of sensory changes, particularly for patients/clients who have peripheral or spinal nerve involvement.
    • Different colors or different hash marks can represent different sensory modalities.
    • Density of hash marks can also be used to demonstrate the severity of sensory change.

Description of involvement including severity (if appropriate) - There is a vocabulary used to describe somatosensation, and clinicians often use a scale to indicate severity of changes:

  • Absent – Decreased – Normal – Hypersensitive – Inaccurate – Inconsistent - Delayed

The patient’s perception of the sensory changes - Ask questions such as "Do the stimuli feel the same or different?", "If different, in what way?", "Do you feel any unusual sensations or lack of sensation?", and "Where?"

Following data collection, the health care practitioner will evaluate the data to determine the diagnosis, prognosis, plan of care, and probable impact of the sensory dysfunction on the patient’s participation in activities of daily living.

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Section: Introduction
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Page 27 of 28
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