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 If present, patients’ identity will remain within the case review process and not
be published or discussed for purposes other than accrediting the applicant.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.
a.
For CT or MRI studies include only the images that demonstrate pathologic findings
b.
Relevant images must be presented in a .jpeg or .pdf format. We will not accept Discs from the
Radiology Department.
c.
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.
d.
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
A. 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.
B. 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.
C. 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.
D. 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.
E. 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.)
F. 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.
G. 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.
H. 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.
I.
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.
J.
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.
K. 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.
L. 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.
M. 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.
N. 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.
O. 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.
P. 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.
Q. 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. Noncompliance 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.
o 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.
o You must however, submit the initial H & P along with the most current H & P performed for the
submitted diagnosis.
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III)
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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)
A)
Errors
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.
2.
3.
5.
6.
B)
Failure to write your name on the disc(s)
Failure to include Case Documentation Form 121 with each case
Failure to provide the proper formatting of the documentation by designating separate folders for
each case and separate files within each case folder
Failure to remove social security number where listed on all documentation
Submitting original discs from Radiology departments or imaging centers. You must submit photos
of the images in JPEG or PDF format
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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Lack of appropriate patient identification on radiographs and appropriate indication of left or right
foot
Incomplete or missing history of present illness
Incomplete or missing biomechanical examination, if appropriate to the case
Missing vital statistics, such as height, weight, etc.
Incomplete or missing review of systems (common error)
Incomplete or missing history of prior treatment
Inadequate documentation of physical examination relative to presenting complaint and patient
history
Inadequate documentation of medication history
Inadequate documentation of primary and/or differential diagnosis
Inadequate documentation of lesion size, shape, depth and description, where indicated
Failure to document treatment plan
Failure to include appropriate radiographic views to depict pathology
Failure to include weight bearing radiographs where appropriate
Inadequate documentation of post-surgical management, where indicated
Inadequate documentation of physical therapy prescription and directions where appropriate
Failure to include the relevant classification system when one is utilized e.g. for muscle testing,
epiphyseal fractures, etc.