Implementation Toolkit
Tool 1:
F686 Survey Readiness Checklist
(for DONs, QA Directors, and Clinical Reimbursement Specialists)
Audit Metric & Focus Area
Audit Criteria & Standards (p. 5)
Compliance Status (p. 5)
- High-Risk Profile
Smoking History, Stroke, Peripheral Arterial Disease (PAD/PVD),
Prior Myocardial Infarction, or History of Ulceration/Amputation
□ Pass
□ Fail
2. Scheduled Every 2 Months
Documentation confirms foot/skin review every 2 months
(thick/yellow nails, tobacco, dry heels bunions/hammertoes)
□ Pass
□ Fail
3. Monthly Attention Log
EHR confirms monthly evaluation for neurological updates
(burning, numbness) and chronic ingrown toenails
□ Pass
□ Fail
4. Weekly Attention Log
EHR confirms weekly check for pre-ulcerative friction markers
(claudication, corns, calluses, toe blisters)
□ Pass
□ Fail
5. Urgent Care
Verification that the 5-Step Clinical Workflow was executed for all Urgent Findings.
□ Pass
□ Fail
Tool 2:
Nurse’s Pocket Guide
NATIONAL DIABETIC LIMB PRESERVATION INITIATIVE POCKET GUIDE
[DG2030 Protocol Alignment – CMS Tag F686 Standards]
Smoking History · Stroke/Myocardial Infarction · Peripheral Vascular Disease ·
Previous Ulceration or Amputation
TIMELINE & MONITORING TRIGGERS
GENERAL (EVERY 2 MONTHS)
- Thick, yellow, brittle toenails (Ch. 5)
- Dry, cracked skin around heel (Ch. 4)
- Active tobacco use (Ch. 3)
- Bunions or Hammertoes (Ch. 9)
ATTENTION (MONTHLY)
- Burning, sharp stabbing, tingling (Ch. 2)
- Frequent or recurrent ingrown toenails (Ch. 5)
- Numbness in the feet (Ch. 2)
SOON (WEEKLY)
- Cramping calf pain when walking (Ch. 3)
- Fluid-filled skin blisters between the toes (Ch. 8)
- Painless corns or calluses (Ch. 6)
URGENT (IMMEDIATE ACTION REQUIRED)
- Leg cramps in bed relieved by walking
- Red, swollen foot (New finding)
- Swollen toe WITHOUT a skin break
- Non-blanching redness (Heel, ankle, lower back, shoulder, sacrum)
- Cold/bluish toes or skin
- Red, swollen skin around nail