Certification | Case Review

Documentation Requirements

After we have received your Case Documentation Transmittal form, a certification panel will chose a number of cases for detailed review:

  • 10 cases for Lower Extremity Medicine or Medicine and Surgery certification
  • 15 cases for Lower Extremity Medicine and Comprehensive Surgery, including Rearfoot and Reconstructive Surgery certification

You will be asked to submit the following documentation for each of the selected cases:

  1. Pre-operative Patient History and Physical as it relates to this procedure
  2. Pre-operative X-rays if applicable
  3. Rationale for Surgery
  4. Lab results and pathology if applicable
  5. Operative Report
  6. Post-operative X-rays if applicable
  7. Progress Notes
  8. Pathology Report if applicable*
  9. Hospital Face Sheet
  10. Discharge Summary

* For tissue removed during case, even if not related to the procedure for which credit is sought.


Your x-rays and images must be on a flash drive, if possible, or a CD.  Photocopies of X-rays are not acceptable. If you chose a CD, you may send a for each patient, or 1 CD with all of your patients’ images as long as they are clearly labeled for each case.  You must include images of relevant CT scans, Nuclear medicine scans, MRIs and x-rays.

Post-operative x-rays and imaging, if performed, should be sent through the end of the surgical healing period, whatever that might be for each patient


It is not necessary for a rationale statement to be contained in the original case record, but you are required to write one if such a statement does not already exist. It must state the indications for surgery, the basis for choosing the procedures performed, the considerations given the patient’s occupation, life style, and personal choices, and a statement why nonsurgical approaches were inappropriate, ineffective, or undesirable.


Every case submitted must come with an operative report printed directly from the Hospital or Surgery Center in which the cases were performed.


Progress notes must be legible. If they are handwritten and illegible, they must be transcribed, and submitted with the typed transcriptions. For each patient visit, progress notes must contain:

  • A chief complaint and initial evaluation of the pathology worked up for surgery
  • A pre-operative History and Physical showing the full pre-op work-up for the patient
  • Indications for surgery-including failed conservative therapy
  • The treatment rendered for the visit being documented with the surgical planning included
  • Follow-up notes throughout the course of recovery.
  • Address any complications from surgery within the progress notes

Progress notes must contain written recitations of X-ray, laboratory, and physical features and how they served as a basis for actions taken or not taken. The mere presence of X-rays, lab reports, or physical examination records is not sufficient. The subjective, objective, assessment, and plan (SOAP) format is encouraged.


All applicable lab reports and pathology reports should be included. This includes pre-operative blood work, chest x-rays, and EKG.

If there was a delay in surgery secondary to medical issues during work-up, please elaborate on how these complications may have been dealt with (for example: If a patient had an abnormal EKG, please provide the cardiac work-up that occurred due to those findings.  If a patient had  a biopsy or tumor removed, please include the pathology report, but also notes from oncology or other specialists you might have referred the patient to as a result of the pathology reports)


Please mail your documentation package to

6210 N. Jones BLVD
PO Box 754000
Las Vegas, NV 89136