Case Review

Documentation Requirements for selected cases

After receipt of Case Log form, a certification panel will choose 10 cases for documentation review:

Applicants must submit the following for each of the selected cases:

Pre-Operative Patient Podiatry History and Physical
Pre-operative X-rays if applicable(all bone procedures) with report
Lab and pathology report copies if applicable
Operative Report
Day of Surgery Post-operative X-rays if applicable (all bone procedures) with report.
Immediate Post-Operative Note describing Sx tolerance, transfer, blood loss, nursing instructions, post op patient instructions including medications prescribed.
Post-Operative Follow Up Visit Progress Note within 15 days of Sx
Pathology Report if applicable
Hospital Face Sheet
Post Operative X-rays (4 weeks or greater showing bone healing) if applicable

Pre-Operative H&P
The Plan should include patient education given, discussion of conservative vs surgical options, and documentation of informed consent.

X-RAYS
Digital copies only. Larger files can be sent as ZIP file or via Dropbox upon request.

OPERATIVE REPORTS
Operative reports must describe the procedure in step wise detail. They should note visualized characteristics of the pathology and anatomy. Dressings/casts applied interoperative should be described.

PROGRESS NOTES
Progress notes must be legible. If they are handwritten and illegible, they must be typed, and submitted with the original. They must be in SOAP or H&P format with X-Ray results thoroughly described.

LABORATORY and PATHOLOGY STUDIES
All applicable Perioperative reports should be included. Actions taken or deferred because of lab findings must be stated.