Case documentation for certification



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CASE DOCUMENTATION FOR CERTIFICATION
Required for applicants with only 24 months of eligible CPME-approved training
Case documentation represents a key aspect of the applicant’s knowledge, and demonstrates practical experience and exposure in the required clinical areas. All cases submitted shall be kept confidential. The patient’s identity, with the exception of their initials, is not required. If present, patients’ identity will remain within the case review process and not be published or discussed for purposes other than accrediting the applicant. Patient names appearing on charts or studies may be blocked out, with only their initials, or other suitable means of identification, showing.
Cases submitted for review will be evaluated with the following goals in mind:

  • Clear and concise documentation, including well-organized diagnostic, evaluative and therapeutic regimes;

  • Where appropriate, examples of interdisciplinary consultation and long-term preventative health care;

  • Appropriate and timely selection of laboratory and imaging studies and response to pertinent findings;

  • Where germane to the case presented, biomechanical evaluations sufficiently detailed to include and justify the pathomechanical diagnosis made and therapeutic regime chosen.  The evaluation is expected to include orthometric findings, gait analysis and manual muscle testing. This is especially true where surgical and/or orthotic options are considered.


It is imperative that case submissions reflect a level of sophistication and relevance to the subject areas listed.
Example of an acceptable level of sophistication and relevance:
Subject: Neurology
A patient is post cerebrovascular accident with unilateral dropfoot deformity, left, and ulcer sub 5th, left, metatarsal head.
Documentation should include evidence of appropriate wound care, biomechanical assessment, consultation/assessment for rehabilitation potential, assessment for orthotic needs, and pedorthic consultation/assessment. The podiatric physician works closely with, e.g., the wound care center, neurologist, occupational therapist, orthotist and pedorthist in resolving the problem.
This case reflects interdisciplinary care, short and long term treatment, and planning for functional capacity. Conversely, a case in which the same pathology would be treated with palliative care alone would not be acceptable.
Cases may be rejected for lack of diversity and/or complexity and/or longitudinal care. Rejected cases will be cause for non-selection to the examination process. There is no appeal of rejected cases.
Initial submission of Form 111 which must be postmarked by March 14, 2015

  • An initial list of forty-eight (48) cases (no more than 48) are due by March 14, 2015 and are to be submitted on Case Summary Index Form 111.

  • A minimum of 14 categories must be utilized. If only 14 categories are utilized no one category can have less than 3 cases. The additional 6 cases may be disbursed among the existing categories or in the “supplemental section” at the end of the form.

 The Case Documentation Review Committee will identify 12 cases for which complete documentation is required.

  1. Enter a diagnosis, patient’s initials, # visits and supporting data on all of the lines in which you make an entry. The diagnosis must be the podiatric diagnosis. For example, in the Diabetes, Endocrine, Metabolic category, do not simply write “diabetes” as the diagnosis.

  2. Although some diagnoses may not have extensive supporting data, where present, please make sure to check the appropriate boxes. This issue cannot be overemphasized. Cases with significant supportive documentation is normally expected, as it provides the reviewers with insight regarding an applicant’s thoroughness in case management. Cases without sufficient supporting documentation may well be viewed as inadequate.

  3. Radiographs and other imaging studies should be included in the “imaging studies” box.

  1. For CT or MRI studies include only the images that demonstrate pathologic findings

  2. Relevant images must be presented in a .jpeg or .pdf format. We will not accept Discs from the Radiology Department.

  3. If hard copy or electronic copy of the actual study is not available and only the written radiology report is present, do not check the imaging studies box. Instead, check the consultation box and subsequently submit the report.

  4. Where both the images and the written report are present, check both boxes.


Rules for Selecting Cases


  1. Cases attended while in a residency program are not eligible.

  2. All cases submitted for the examination year must have been performed within seven years of the year submitted.

  3. Cases submitted for review in a previous year may not be resubmitted.

  4. Make certain that all of your records are complete for all 48 cases before you submit the initial list.

  5. It is forbidden to use the same patient more than once. If two patients have the same initials, differentiate them by including a middle initial or number following the initials, (i.e. TAM and TRM or TM1 and TM2).

  6. The applicant must be the predominant practitioner of record for podiatric management. If not, a letter explaining the circumstances must accompany the documentation for that case.


CASE SUMMARY INDEX GUIDE
The descriptions within each category (A through Q) are intended to assist you in developing your case summary index (Form 111) and subsequent documentation. The Case Documentation Review Committee is aware that many cases may legitimately cross two or more categories. As a result, it is inevitable that some of the information in a given category may overlap with that of another category. While only one case may be utilized per category, the cross-categorization that may exist in some of your cases should work to your advantage when allocating cases to different categories. It is absolutely essential, however, that the pathology described within a case is appropriate to the category in which it is placed and is of sufficient complexity to be considered at a level appropriate to a Diplomate of this board.
DESCRIPTION OF CATEGORIES FOR CASE SUBMISSION


  1. BIOMECHANICS, PATHOMECHANICS:

Cases in this category include:

  • mechanically induced pathology such as plantar fasciitis/heel spur syndrome

  • pathomechanically related deformity such as bunions, hammertoes, first ray pathology, structural or functional equinus, hallux limitus, pes planus, etc.

  • compensatory gait abnormalities and mechanically induced dermatologic lesions such as keratoses

  • superstructurally referred symptomatology from pedal and lower extremity pathology

This category excludes sports related or acute trauma, and podopediatrics (if age 14 or younger). Cases submitted must provide documentation of relevant orthometric/biomechanical data and gait analysis. Orthotic, pedorthic or prosthetic use should be a part of the therapeutic regime in the majority of cases.




  1. DIABETES, ENDOCRINE, METABOLIC: Cases in this category include problems where management of the podiatric condition was modified by the presence of systemic disease such as Diabetes type 1, Diabetes type 2, thyroid disease, parathyroid disease, hypoglycemia, osteoporosis, osteomalacia, rickets, etc.




  1. PODIATRIC MEDICINE: Cases in this category should reflect commonly encountered pathology such as neuroma, non-sports medicine related conditions such as bursitis, capsulitis, periostitis, tendonitis, plantar fat pad atrophy, symptomatic exostoses, overuse syndromes, stress fracture, uncomplicated sprains and strains, etc.




  1. GENERAL MEDICINE: Cases in this category include podiatric manifestations of systemic disease. It includes but is not limited to cardiology/pulmonology, hematology/oncology and gastroenterology/ nephrology.




  1. GERIATRICS: Cases in this category include problems where management of the podiatric condition was modified as a result of clinical or sociologic factors affecting senior citizens (i.e. nutritional classification, osteoporosis, anticoagulant therapy, polypharmacy, drug interaction, dementia, care-giver issues, transportation, ambulatory classification, perioperative management.)




  1. INFECTIOUS DISEASE: Cases in this category may include infection resulting from inoculation, trauma, chronic wounds, or orthopedic deformity with secondary ulceration. Management of the systemic and/or local process must be documented.




  1. GENERAL ORTHOPEDICS: Cases in this category may include acute traumatic conditions such as sprain, fracture, or tendon rupture; post traumatic or acquired deformity such as structural limb length inequality, fixed equinus, triple flexion contracture, deformity secondary to muscle paresis or dynamic imbalance; mechanically induced degenerative joint disease. Pedorthic, orthotic or prosthetic use may be a part of the therapeutic regime in many cases. Appropriate radiographic or other imaging studies should be included in this category.



  1. NEUROLOGIC DISEASE: Cases in this category include the podiatric manifestations of neurologic and neuromuscular disease such as CMT, CVA, muscular dystrophy, ALS, and neuropathic disease such as mal-perforans ulceration. Pedorthic, orthotic or prosthetic use and wound care modalities may be a part of the therapeutic regime in many cases.




  1. PEDORTHICS: Cases in this category include podiatric conditions in which management requires the prescription of depth inlays, custom molded shoes, shoe wedges or build-ups, and assistive devices such as crutches, canes or walkers.




  1. PERIPHERAL VASCULAR DISEASE: Cases in this category may include podiatric manifestations of vascular disease such as venous and arterial ulcers, arteriosclerosis, acrocyanosis, lymphedema, Raynaud’s phenomenon or disease, other vasospastic disease, frostbite, pernio, manifestations of RSDS, etc.




  1. PODIATRIC DERMATOLOGY: Cases in this category include acute and chronic dermatologic conditions, nail pathology and neoplastic disease (i.e. tinea pedis, candida, verruca, xerosis, dermatitis, nail dystrophies, melanoma, etc. This category excludes pathomechanical, peripheral vascular or neuropathically induced lesions.




  1. PODIATRIC RADIOLOGY: Cases in this category include pathology in which diagnostic imaging is a key component to subsequent management. Identification and differentiation of such conditions as occult trauma, metabolic disease of bone, neoplasms, infection, and arthropathies with studies such as bone scans, arthrography, CT, and MRI, as well as plain radiographs, alone or in combination, are expected to be documented.




  1. PODOPEDIATRICS: Cases in this category include patients from infancy through adolescence and includes pathology impacted by the developing musculoskeletal system. Conditions such as torsional/rotational disorders, epiphyseal dysplasias, congenital deformity, pediatric trauma and pediatric arthritidies should be documented. Pediatric radiology should be included in this category. Cases submitted must provide documentation of relevant orthometric/biomechanical data. Cast therapy, bar or brace therapy, orthotic and pedorthic use should be a part of the therapeutic regime in many cases.




  1. REHABILITATION, PHYSIOTHERAPY: Cases in this category include long term rehabilitation following trauma, rheumatologic disease, neurologic disease, iatrogenic deformity (i.e. failed surgeries) and chronic wound management, featuring appropriate therapies such as compressive or off-weight bearing modalities. Therapy should emphasize increase of function. Orthotic, pedorthic or prosthetic use may be a part of the therapeutic regime in many cases.




  1. RHEUMATOLOGY: Cases in this category include the podiatric manifestations of rheumatologic disease such as Rheumatoid arthritis, Reiter's syndrome, Psoriatic arthritis, Gout, Osteoarthritis and traumatic arthritis. Cases should emphasize rehabilitation and the management of orthopedic deformities and other patient limitations resulting from the disease entity. Orthotic, pedorthic or prosthetic use may be a part of the therapeutic regime in many cases.




  1. SPORTS MEDICINE, TRAUMA: Cases in this category include acute soft tissue and osseous trauma of the lower extremity secondary to athletic endeavors such as overuse syndromes; training errors that have either contributed to a problem or resulted in injury; and factors which complicate therapy, such as maintaining cardiovascular fitness in an athlete that must be non-weight bearing. Appropriate radiographic or other imaging studies should be included in this category.




  1. WOUND CARE: Cases in this category include acute and chronic dermal ulcerations with or without osseous sequelae, (e.g. osteomyelitis), deformity and infarction. Etiology may include trauma, infection, peripheral vascular disease, neurologic deficiencies, metabolic aberrations, etc. Work up should include appropriate inter-disciplinary management of the pathogenesis, timely treatment and consultation, management of pathomechanical sequelae (e.g. orthotic, pedorthic, prosthetic and/or surgical intervention), and long-term preventative measures.


GUIDE TO PREPARATION OF CASES FOR CERTIFICATION
I) Introduction

  • It is important that you read and follow these instructions thoroughly.

  • Give particular attention to the areas in bold, italic, or underlined type.

  • You may view the sample CD on our website indicating the proper format for case presentation. Non-compliance with the instructions contained therein may result in the rejection of cases.

  • Notification of pass/fail results for case documentation will be sent in writing within 2 weeks of the case review process.



II) Preparing Your Cases


  • 12 fully documented cases are required

  • Digitized copies of all original chart notes, consultation reports, laboratory reports, pathology reports, etc., must be provided.

  • Please be sure to remove or completely cover any patient’s social security number on any documents before creating the Disc. Patient names and date of birth is optional and leaving it as part of the documentation is in compliance with HIPAA.

  • Handwritten chart notes are not accepted. A typed version must be provided.

  • Hospital or other institutional notes must be scanned but do not need to be typed.

  • Radiographs, pathology, lab reports, etc. must be organized into separate folders from the chart notes.

    • The contents of each folder must be submitted in chronological order.

  • Cases in which a patient has been followed for an extended period of time require only the portion of the case relating to the diagnosis provided on Form 111.

    • You must however, submit the initial H & P along with the most current H & P performed for the submitted diagnosis.

III) Formatting Your Cases



  • Cases must be submitted on CD or thumb drive.

  • The preferred file format is PDF and all files must have the ability to open in a Windows environment. Cases must be organized in the following manner:

Folder – Case Number and Patient Initials (e.g. B5 C.J.)

Folder Contents

(Files A & B are mandatory. Additional files are expected, but are created based on the

content of each case):

Note: As folders and files are computer generated, headquarters is aware that the order of files may not appear as listed below.



File A – Form 121

File B – Chart notes

File C – Imaging studies

File D – Biomechanical exams

File E – Laboratory reports

File F – Consultation reports

File G – Pathology reports
3) Board Headquarters recommends that the cases be sent via certified or registered mail and applicants retain a copy of their receipts. Applicants should retain a copy of all submissions as originals will not be returned.
4) Send the original disc or thumb drive bearing your name to:
ABPM Headquarters

3812 Sepulveda Blvd, Suite 530

Torrance, CA 90505
IV) Errors
A) Common Errors in Preparation of Cases

The following are common errors that we find in the preparation of cases. Since it is the Board’s desire that you pass your case documentation process, you will find that the following lists of errors are repetitions of the instructions found elsewhere in this guide. They are listed for emphasis. Refer to this list before you seal and mail your disc(s) to us.


1. Failure to write your name on the disc(s)

2. Failure to include Case Documentation Form 121 with each case

3. Failure to provide the proper formatting of the documentation by designating separate folders for each case and separate files within each case folder

5. Failure to remove social security number where listed on all documentation

6. Submitting original discs from Radiology departments or imaging centers. You must submit photos of the images in JPEG or PDF format
B) Common Errors in Charting

The following are common podiatric/medical errors that we find occurring repeatedly in the applicant’s chart records in the handling of their patients:


1. Lack of appropriate patient identification on radiographs and appropriate indication of left or right foot

2. Incomplete or missing history of present illness

3. Incomplete or missing biomechanical examination, if appropriate to the case

4. Missing vital statistics, such as height, weight, etc.

5. Incomplete or missing review of systems (common error)

6. Incomplete or missing history of prior treatment

7. Inadequate documentation of physical examination relative to presenting complaint and patient history

8. Inadequate documentation of medication history

9. Inadequate documentation of primary and/or differential diagnosis

10. Inadequate documentation of lesion size, shape, depth and description, where indicated

11. Failure to document treatment plan

12. Failure to include appropriate radiographic views to depict pathology

13. Failure to include weight bearing radiographs where appropriate

14. Inadequate documentation of post-surgical management, where indicated



15. Inadequate documentation of physical therapy prescription and directions where appropriate

16. Failure to include the relevant classification system when one is utilized e.g. for muscle testing, epiphyseal fractures, etc.


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