certification | Case Review

Documentation Requirements for Selected Cases

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┬ácertification

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.

X-RAYS

Photocopies of X-rays are not acceptable. You may send us film or use digital media. If you chose the latter, you may send a CD or DVD for each patient. You may also combine all files onto a single inexpensive USB stick using filenames that indicate what the file contains and which patient it belongs to. For example, if case number 5 is Mrs. Tina Jones and the X-ray is pre-op, use a file name like Case5_Jones_Pre.jpg, so the examiner will know immediately which X-ray file belongs to which patient case. Pre-operative X-rays should include written criteria for choice of procedure. Post-operative X-rays should include weight-bearing X-rays, either immediate post-op or within three weeks of the procedure.

RATIONALE FOR SURGERY

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.

OPERATIVE REPORTS

Operative reports must be sufficiently detailed to permit the reader to visualize the procedure, and written for a reader who knows nothing about the specific procedures in the report. They should indicate locations and sizes of incisions and osteotomies, indicate the sizes of bone fragments removed, provide details on osteotomy procedures, and intraoperative observations of corrections achieved. They must contain pre-operative and post-operative diagnoses and the name of the surgeon, and they must be signed. Template-style reports are not acceptable.

PROGRESS NOTES

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
  • A limited physical examination as circumstances permit (a surgical case warrants a full physical examination performed within a reasonably short time before surgery)
  • The results of prior treatment
  • The treatment rendered for the visit being documented.

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.

LABORATORY STUDIES

All applicable lab reports should be included, with abnormal results indicated thereon, and referenced in the progress notes. Actions taken or deferred because of lab findings must be stated. A clinical approach to dealing with abnormal laboratory levels must be indicated.

SUBMISSION OF DOCUMENTATION

Please mail your documentation package to the address on our home page. If you chose to use FedEx, UPS, or another shipping service, please contact us for an alternative address. Call us if you’d like our assistance in determining the best and most cost-effective method of shipping, and please make a copy of your documentation for your files before you send it.