Documenting a monofilament test requires recording the patient’s identifying information, the specific sites tested, whether each site was felt or not felt, and an overall interpretation of sensation loss. The 10-gram Semmes-Weinstein monofilament examination is the most widely used bedside screening tool for peripheral neuropathy, particularly in people with diabetes, and its value depends entirely on consistent, site-by-site documentation that another clinician can read and act on months later. Getting the documentation right is straightforward once you know what to capture and why each element matters.
What to Record Before Touching the Patient
Every monofilament test record starts with baseline information that gives context to the results. This includes the patient’s name or identifier, the date of the examination, and which limb or limbs you are testing. If you are using a standard 5.07/10-gram monofilament (the most common gauge for diabetic foot screening), note that explicitly. Some clinics use graded monofilament kits with multiple thicknesses for more detailed sensory mapping, particularly when assessing hand sensation. The gauge matters because a result recorded as “absent” means something very different depending on whether you applied a 10-gram or a 1-gram filament.
You should also note whether the patient has any calluses, open wounds, or scars at the planned test sites, because thickened or damaged skin can produce a false “insensate” result that has nothing to do with nerve function. A brief note like “callus present at first metatarsal head, site skipped” saves the next examiner from misinterpreting the record. If the patient has had a prior amputation, document which toes or areas are missing so the chart reflects the actual anatomy tested.
Choosing and Mapping the Test Sites
The number of sites you test on each foot varies by protocol, and this is one of the most important details to document because it affects how the results should be interpreted. Common protocols call for three, four, eight, or ten sites per foot. Research comparing these approaches has found that the diagnostic accuracy does not change dramatically when you go from three sites to ten. One study comparing three-site, four-site, and ten-site protocols found no significant differences in screening effectiveness, suggesting that testing three sites on each foot may be sufficient for routine neuropathy screening.1PubMed Central. Easier operation and similar power of 10 g monofilament test for screening diabetic peripheral neuropathy Another study looking at similar site comparisons reported that sensitivity and specificity at three and four points were not statistically different from eight- and ten-point testing.2PubMed Central. Comparison of the accuracy of monofilament testing at various points of feet in peripheral diabetic neuropathy screening
That said, many guidelines still recommend testing at least four plantar sites. The most commonly used locations on the sole of the foot are the great toe (plantar surface of the distal phalanx), the first metatarsal head, the third metatarsal head, and the fifth metatarsal head. Some protocols add the heel, the dorsum of the foot, and the medial and lateral midfoot. Whichever protocol your facility uses, document the exact sites you tested. A foot diagram printed on the chart or electronic template, where you can mark each location as “felt” or “not felt,” is far more useful than a written note like “decreased sensation bilateral feet,” which tells the next clinician almost nothing about where the problem is or how it has changed over time.
How to Perform the Test so Your Documentation Is Meaningful
Technique directly affects whether your documented results are reliable, so the method you use is worth noting briefly in the record. The standard approach is to hold the monofilament perpendicular to the skin and press until the nylon fiber just bows into a C-shape, then hold for about one to two seconds before releasing. The patient should not be watching, so ask them to close their eyes or look away. Apply the filament to each site and ask the patient to say “yes” when they feel it, or to indicate which foot or area is being touched.
A common practice is to apply the monofilament three times at each site, with at least one “sham” application where you go through the motion without actually touching the skin. This helps you distinguish genuine sensation from guessing. A site is typically scored as “insensate” if the patient fails to detect the monofilament on two out of three applications. Document the method you used: “3 applications per site, 1 sham” or “single application per site” tells the reader how rigorous the test was. If you used a different threshold for calling a site insensate, note that too.
Avoid pressing the monofilament onto callused skin, ulcer edges, scar tissue, or areas of active inflammation. If you must skip a site, mark it as “not tested” rather than leaving it blank, because a blank space is ambiguous: it could mean the site was normal, or it could mean you forgot to test it.
Recording Site-by-Site Results
The core of monofilament documentation is a site-by-site record showing whether sensation was present or absent at each tested location. The simplest and most widely used format is a foot map (sometimes called a sensory map or monofilament diagram) printed on the assessment form. Each test site is marked with a circle on a diagram of the plantar and sometimes dorsal foot surface. You fill in each circle: a plus sign or filled circle for “felt,” and a minus sign or open circle for “not felt.” Many electronic health records have standardized templates for this.
If your documentation system does not have a diagram, write out the results in a list format. For example:
- Right foot: Great toe – not felt; 1st metatarsal head – felt; 3rd metatarsal head – felt; 5th metatarsal head – not felt
- Left foot: Great toe – felt; 1st metatarsal head – felt; 3rd metatarsal head – felt; 5th metatarsal head – felt
This format is less intuitive at a glance than a diagram, but it is explicit and leaves no room for interpretation. Include both feet even if only one is symptomatic, because neuropathy is often bilateral and comparing sides is clinically useful for tracking progression.
Scoring and Interpreting the Results
After recording each individual site, summarize the findings with a score. The most straightforward scoring method is to count the number of insensate sites out of the total tested: for example, “2/8 sites insensate, right foot” or “0/4 sites insensate, left foot.” Some protocols use a threshold: if one or more sites are insensate, the test is considered positive for loss of protective sensation. Others require two or more insensate sites. Document which threshold your facility uses so the interpretation is transparent.
The overall clinical interpretation should also appear in the record. A typical documentation note might read: “Loss of protective sensation identified at the great toe and fifth metatarsal head of the right foot, consistent with peripheral neuropathy. Patient counseled on daily foot inspection and appropriate footwear.” This connects the test findings to a clinical action, which is the whole reason you are doing the test in the first place.
The 10-gram monofilament test has strong specificity for diabetic peripheral neuropathy. One study using nerve conduction studies as the reference standard found that the monofilament test had a specificity of 100% and an overall accuracy of about 91%, though its sensitivity was around 80%, meaning it misses roughly one in five cases of neuropathy that nerve conduction studies would catch.3The Egyptian Journal of Neurology, Psychiatry and Neurosurgery. Semmes Weinstein monofilament test for detection of diabetic peripheral neuropathy: sensitivity and specificity That gap in sensitivity is worth keeping in mind: a “normal” monofilament test does not completely rule out neuropathy, and your documentation should reflect that distinction. Rather than writing “no neuropathy,” write “protective sensation intact by monofilament” and let the clinical picture determine whether further testing is needed.
When to Combine the Monofilament Test with Other Assessments
Because the monofilament test checks only one type of nerve fiber (the large myelinated fibers responsible for pressure sensation), many screening protocols recommend pairing it with at least one other test to improve detection. A 128 Hz tuning fork, which tests vibration perception, is the most common companion. Research has found that combining the monofilament with tuning fork testing and a basic foot appearance exam produces a composite screening tool that correlates well with nerve conduction study results.4PubMed Central. Intra- and Inter-Rater Reliability, Parallel Test Reliability, and Internal Consistency of the Tuning Fork and Monofilament Tests
If you perform additional tests alongside the monofilament, document each one separately with its own results. A combined note might look like: “10 g monofilament: 1/4 sites insensate, right foot. 128 Hz tuning fork: diminished vibration sense at right great toe. Ankle reflex: absent bilaterally.” This composite approach gives a more complete picture and is recommended by multiple diabetes care guidelines for annual foot examinations.
Reliability and What It Means for Your Records
A test is only as useful as it is reproducible. If two clinicians test the same patient and get wildly different results, the documentation becomes unreliable for tracking changes over time. Research on the monofilament test’s reliability is encouraging for foot and ankle testing but less so for other body regions. One study found good to moderate agreement between examiners when testing foot and ankle locations, but poor reliability when testing the leg, thigh, and trunk.4PubMed Central. Intra- and Inter-Rater Reliability, Parallel Test Reliability, and Internal Consistency of the Tuning Fork and Monofilament Tests Another study specifically evaluating the 4-2-1 stepping algorithm (a systematic method of testing progressively thinner monofilaments to find the exact detection threshold) reported moderate to good inter-rater and intra-rater reliability in healthy adults.5Muscle and Nerve. Interrater and intrarater reliability of the semmes-weinstein monofilament 4-2-1 stepping algorithm
What this means practically: your documentation should include enough detail about the method that a different clinician performing the same test next year would use the same technique, the same sites, and the same threshold for calling a site insensate. If your clinic has a standard protocol posted or embedded in the electronic record template, referencing that protocol by name is sufficient. If there is no standard and you are making judgment calls about sites or technique, write those choices down.
Documentation for Hand and Upper Extremity Testing
Although most clinicians associate monofilament testing with diabetic foot screening, the same tool is used to assess sensation in the hand, particularly when evaluating conditions like carpal tunnel syndrome. The documentation principles are the same, but the anatomy and protocols differ. In hand testing, the monofilament is typically applied to the fingertips (the palmar surface of the distal phalanx) of the thumb, index finger, and middle finger, which are the digits innervated by the median nerve. Some protocols include the small finger as a control, since it is innervated by the ulnar nerve and should be unaffected in carpal tunnel syndrome.6PubMed. Decision making in detecting abnormal Semmes-Weinstein monofilament thresholds in carpal tunnel syndrome
Hand testing often uses a graded set of monofilaments rather than just the 10-gram filament, because the hands have much finer sensory discrimination than the feet. The clinician applies progressively thinner filaments to find the lightest one the patient can detect at each fingertip. In one approach, the monofilament is applied three times to each digit tip with the wrist in a neutral position, and the threshold for each digit is recorded as a numerical value representing the filament strength.7PubMed Central. What is the role of Semmes-Weinstein monofilament testing in the diagnosis of electrophysiologically graded carpal tunnel syndrome? When documenting graded monofilament testing in the hand, record the threshold filament number or its corresponding force for each digit tested, along with the wrist position during testing (neutral, flexed, or extended). A change in threshold over serial exams can indicate worsening or improving nerve compression.
Alternatives That May Show Up Alongside Monofilament Documentation
In settings where a monofilament is unavailable or impractical, the Ipswich Touch Test (IpTT) is sometimes used as a substitute. This test uses the examiner’s fingertip rather than a monofilament, making it free and requiring no equipment. Clinicians who use both tests in the same visit sometimes document both results side by side. Research comparing the IpTT to the standard 10-gram monofilament has shown strong agreement between the two. One study found the IpTT had a sensitivity of about 83% and a specificity of about 98% when compared to the monofilament as the reference.8PubMed Central. Is it possible to substitute the monofilament test for the Ipswich Touch Test in screening for peripheral diabetic neuropathy? Another study comparing both tests against vibration perception threshold testing found that the monofilament had slightly higher sensitivity (about 95%) and similar specificity to the IpTT.9PubMed. Comparing the Ipswich Touch Test (IpTT) and 10gm-SMWF (10-gm Semmes-Weinstein mono-filament) in Indian population subset with type 2 diabetes mellitus to detect diabetes neuropathy
If you use the IpTT, document it clearly as a distinct test so it is not confused with a monofilament exam. A note like “Ipswich Touch Test performed (monofilament not available): sensation present at all tested sites bilaterally” prevents ambiguity. If both tests are used, record each with its own results.
Common Documentation Mistakes
The single most common error is writing a vague summary without site-specific data. “Monofilament test normal” or “decreased sensation noted” tells you almost nothing. It does not tell you which sites were tested, how many were abnormal, or which foot was affected. A record like that cannot be compared to a future exam to determine whether the patient’s neuropathy is progressing, stable, or improving.
Another frequent problem is failing to document the monofilament gauge. In diabetic foot screening, you almost always use a 10-gram (5.07 log) monofilament, but clinicians who do not record the gauge leave room for confusion, especially if the patient later undergoes graded testing with a full monofilament kit. Recording “10 g Semmes-Weinstein monofilament” takes a few seconds and eliminates that ambiguity.
Leaving sites blank instead of marking them “not tested” creates records that look normal when they are actually incomplete. This is especially problematic in patients with amputations or ulcers, where certain sites cannot be tested. Every site on your protocol should have one of three marks: felt, not felt, or not tested.
Finally, some clinicians skip the patient’s footwear and self-care education documentation that should accompany an abnormal result. Guidelines for diabetes foot care generally tie the monofilament test to a risk-stratification step. If you find loss of protective sensation, the visit note should document not just the finding but the clinical response: referral to a podiatrist, footwear recommendations, patient education about daily foot checks, or a follow-up interval. Without that, the test result sits in the chart as an isolated data point rather than a trigger for preventive action.
Monofilament Maintenance and Its Place in the Record
Nylon monofilaments lose their calibration over time, especially with heavy use. A filament that has been applied hundreds of times may deliver less force than it did when new, which can cause false “insensate” results. Some quality-assurance protocols recommend replacing disposable monofilaments after a set number of patients (commonly 10 to 20) or allowing the filament to recover its shape for 24 hours after prolonged use. While you do not need to document the age of your monofilament on every patient chart, clinics that maintain quality-assurance logs should track monofilament replacement dates. If a batch of unexpected abnormal results coincides with using a worn-out filament, that log becomes essential for understanding whether the results reflect true neuropathy or equipment degradation.
For clinics using reusable monofilament kits (the type with multiple graded filaments in a case), periodic calibration checks are part of good practice. A simple documentation step for these kits is recording the kit identifier or serial number along with the date of last calibration. This is more common in research settings and hand therapy clinics than in routine primary care, but it becomes relevant anywhere that serial measurements are being compared over months or years.