AOBOS
Clinical Exam
Handbook
American Osteopathic Board of
Orthopedic Surgery
Board Members
Marko F. Krpan, DO, Chair
Sean O’Brien, DO, Vice-Chair
Nathan Melton, DO Secretary
John Schlechter, DO
Jonathan Wigderson, DO
142 E. Ontario Street
Chicago, IL 60611
Phone: 312.202.8208
Email: aobos@osteopathic.org
Table of Contents
FOR CANDIDATES ........................................................................................................................1
INTRODUCTION ..................................................................................................................................................... 1
Objective of the Clinical Examination ................................................................................................................ 1
Board Eligibility .................................................................................................................................................. 1
EXAM PROTOCOL................................................................................................................................................... 3
Snapshot of the Overall Clinical Examination Process ......................................................................................... 3
THE CLINICAL EXAMINATION STEP BY STEP ........................................................................................................... 4
Step 1 - Application and Surgical Log Submission ................................................................................................ 4
Major VS. Minor Cases .................................................................................................................................. 4
Cases vs. Procedures ..................................................................................................................................... 5
Complications and Outcome .......................................................................................................................... 5
Clinic Cases ................................................................................................................................................... 6
Mortalities .................................................................................................................................................... 6
Surgical Log Template.................................................................................................................................... 6
Surgical Log Template Cont’d ........................................................................................................................ 7
Step 2 - Examiners are Assigned ......................................................................................................................... 9
Step 3 - Senior Examiner Chooses Charts ............................................................................................................ 9
Step 4 – Candidate Examination ......................................................................................................................... 9
Chart Preparation General Guidelines ............................................................................................................ 9
Clinic Cases ................................................................................................................................................. 12
Redaction .................................................................................................................................................... 12
Chart Review Grading (Please see the rubric for greater detail) .................................................................... 12
Case Defense............................................................................................................................................... 12
Case Defense Grading (Please see the rubric for greater detail) ................................................................... 13
Step 5 – Scores are Determined ....................................................................................................................... 13
FOR EXAMINERS ........................................................................................................................14
INTRODUCTION ................................................................................................................................................... 14
EXAM PROTOCOL................................................................................................................................................. 14
Step 1 - Application Process (Candidate) .......................................................................................................... 14
Step 2 - Log Approval (Board) ........................................................................................................................... 14
Step 3 - Examiners Assignments (AOBOS Staff and Examiner Volunteers) ......................................................... 14
Step 4 - Chart Selection and Communication to Candidate (Senior Examiner) .................................................. 14
Step 5 - Chart Preparation and upload (Candidate) ........................................................................................... 15
Step 6 - Examiner Chart Review, Case Defense or Exit Interview Zoom Meeting (Sr. and Jr. Examiners plus
Candidate for Meeting) .................................................................................................................................... 15
Step 7 - Scores are Determined (AOBOS) .......................................................................................................... 15
RESPONSIBILITIES ................................................................................................................................................ 15
Senior Examiner ............................................................................................................................................... 15
Junior Examiner ............................................................................................................................................... 16
GUIDELINES FOR SELECTING CASES FOR CHART REVIEW...................................................................................... 16
SUBSPECIALTY ORTHOPEDIC SURGEONS ............................................................................................................. 17
CHART REVIEW .................................................................................................................................................... 17
Chart Review Grading ...................................................................................................................................... 18
Pre Operative Care & Evaluation.................................................................................................................. 18
Chart Mechanics ......................................................................................................................................... 18
Indications for Surgery ................................................................................................................................ 18
Performance of Surgical Procedure.............................................................................................................. 18
Quality of Follow-Up Care............................................................................................................................ 19
Holistic Impression ...................................................................................................................................... 19
Post Observation Letter to the Board........................................................................................................... 19
Chart Review – Mortality Review ..................................................................................................................... 19
CASE DEFENSE...................................................................................................................................................... 20
Case Defense Grading ...................................................................................................................................... 20
Patient Presentation, Relevant History ........................................................................................................ 20
Interpretation of Studies ............................................................................................................................. 20
Medical Knowledge ..................................................................................................................................... 20
Medical Decision Making ............................................................................................................................. 20
Post-Op Protocol / Outcomes ...................................................................................................................... 21
FOR CANDIDATES AND EXAMINERS ...........................................................................................22
RUBRICS ............................................................................................................................................................... 22
AOBOS Clinical Chart Review Scoring Rubric ........................................................................................................ 22
AOBOS Clinical Case Defense Scoring Rubric ........................................................................................................ 27
A O B O S C L I N I C A L H A N D B O O K
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FOR CANDIDATES
INTRODUCTION
The information in the enclosed booklet will assist you in proceeding with the Clinical Examination. Board
certification in Orthopedic Surgery is administered by the American Osteopathic Board of Orthopedic
Surgery for the American Osteopathic Association (AOA). It requires the successful completion of a
written examination and a clinical review with an oral defense. The clinical review with oral defense
consists of a chart review and oral defense of cases.
Objective of the Clinical Examination
The objective of the Clinical Examination is to evaluate a candidate’s surgical practice by review of
their medical records and oral defense of a subset of cases. To accomplish this goal, two board-
certified orthopedic surgeons will review the medical record with particular emphasis on
presurgical evaluation and preparation, postoperative management, surgical judgment, and
overall patient care. Twelve cases will be reviewed in detail, and five of the twelve cases will be
chosen for case defense. Please review the scoring rubrics found at the end of the handbook for a
detailed scoring breakdown.
It is imperative that the medical record reflects the candidate’s active management of the case.
Documents including, but not limited to, the history and physical exam, daily progress notes,
consults, operative reports, pre-op/post-op orders, and discharge summaries MUST reflect the
candidate’s personal involvement. Notes authored by house officers, residents, fellows,
physician assistants, nurse practitioners, etc., that are countersigned ONLY, do not satisfy this
requirement. A separate note or addendum performed the same day documenting the patient
evaluation, examination, impression, and plan is required.
If H&Ps are done by other physicians, the candidate must duplicate that process to show thier
involvement in the case and management of decisions. The candidate physician must have
personal documentation that they have done a pre-op evaluation and documented the rationale
for surgery. If necessary, the candidate physician can attach an addendum to the chart explaining
his/her pre-op evaluation, diagnosis, and indications outlining the patient treatment plan.
Board Eligibility
Board Eligibility is necessary to participate in the AOBOS certification process. The only exception is the
Written Exam which can be taken in the fourth or fifth year of residency. Fourth-year residents must
provide an approval letter from the Program Director.
Board Eligibility is automatic. Board Eligibility begins after the successful completion of your Orthopedic
Residency and confirmation of ‘Training Complete’ status by the Residency Program Director.
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You will be considered board eligible for six (6) years after the completion of your residency until 12/31
of the sixth year. Board eligibility begins upon residency completion, a fellowship year would occur
during your board eligibility period. For example, if the date you completed your residency was
6/30/2021, your board eligibility would expire 12/31/2027.
For those candidates who were or became board eligible during 2020 an extra year of eligibility has been
added due to the pandemic.
Board eligibility policy is set by the Bureau of Osteopathic Specialists (BOS) the governing body for all
osteopathic certifying boards. To see the board eligibility policy and options upon the expiration of board
eligibility please see the BOS Handbook; Article VI. Board Eligibility.
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EXAM PROTOCOL
Snapshot of the Overall Clinical Examination Process
1) Application
a) Surgical log must be submitted with the application. Log includes ALL major cases in 6
consecutive months. The minimum number of cases is 100. Collection may continue up to
18 months if 100 cases is not achieved in 6.
The Surgical Log serves as a representative snapshot of your practice. It will provide the pool
from which your senior examiner will select cases for you to prepare for the Clinical
Examination. The materials for all of the cases in your log MUST be available to you to
gather for your exam.
b) Mortality report must also be included for any mortality within 30 days of surgery.
c) PLEASE NOTE: The application can be closed at any time due to reaching maximum testing
capacity The number of examiners is limited, requiring us to cap the number of candidates
per cycle. Apply early to secure your spot.
2) Application review and log approval.
a) AOBOS staff confirms the application is complete and does initial review of the surgical log.
b) A member of the AOBOS Board reviews the surgical log and mortality report (if applicable).
c) Candidate is notified if log or mortality report revisions are required or if the log is approved.
3) Examiners are assigned.
4) Contact information for the candidate and both examiners is emailed to all parties. Examiners
are sent their candidate's surgical log and mortality report (if applicable). A schedule with due
dates is distributed to all parties.
5) Senior examiner selects cases from the surgical log to prepare for the examination.
The selection will span the log collection period, be representative of the breadth of practice, and
include cases that vary in complexity.
6) Examiners and candidates follow the cycle schedule for each portion of the exam.
a) Examiner case selection and communication to candidate. (~ 12 Days)
b) Candidate case material preparation and upload to secure file share. (~ 35 Days)
c) Examiner review of case material, scheduling and execution of case defense Zoom meeting.
(~ 55 Days)
d) Examiner evaluation submission to the Board.
e) Grades are posted within 12 weeks of the Final Examiner Grading Submission Deadline.
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THE CLINICAL EXAMINATION STEP BY STEP
Step 1 - Application and Surgical Log Submission
Candidates may complete the application and pay the examination fee to hold a spot in a clinical exam
cohort. You must add your required documents before the published first deadline date to complete
your application.
You must have been in practice post-residency (and fellowship if applicable) for a minimum of one year
at the time of surgical log submission.
ALL major surgeries where you are the primary surgeon during the collection period must be included in
the surgical log. The collection period must cover 6 consecutive months and include a minimum of 100
cases. ALL major cases in the 6 months must be included, collection does not end when 100 cases are
reached. If you do not reach 100 cases in the 6 months, collection may continue for up to 18 months.
The oldest eligible cases for inclusion are those occurring up to one year before the exam application
opening date (for candidates needing 18 months to reach the 100 case minimum this would be 18
months). The most recent eligible cases for inclusion are those occurring on the day of the first
application deadline.
The Surgical Log serves as a representative snapshot of your practice. It will provide the pool from which
your senior examiner will select cases for you to prepare for the Clinical Examination. The materials for
all of the cases in your log MUST be available to you to gather for your exam.
Mortalities apply to deaths that occur within 30 days of the surgical procedure. Mortalities are to be
listed both in the category of primary treatment and under Category I (Mortalities). All mortalities
require a summary report to be personally authored by the candidate and submitted as part of the
documentation necessary for the Clinical Exam application. A Mortality Report Template can be found
on the AOBOS website.
All surgical logs are subject to audit. If a candidate’s surgical log is selected for audit, the AOBOS will
require the hospital(s) surgical record for the candidate’s recording period before their surgical log will
be approved.
Major VS. Minor Cases
The AOBOS uses the criteria established in the RBRVS, Resource Based Relative Value Scale (the
physician payment schedule for Medicare) for what constitutes major vs. minor cases. Use the RBRVS
(Resource Based Relative Value Scale) to look up the code in question. If it has a 90 day Global Period,
the case is considered major. If it has a 0-10 day Global Period, the case is considered minor.
If you do not have access to the RBRVS code book, you can access the Medicare website
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-
Value-Files.html to use the Physician Fee Schedule Look-Up Tool.
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Cases vs. Procedures
The log is intended to report “cases”, not procedures. A “case” is a patient contact or encounter, for
which multiple surgeries or procedures may have been performed under the same anesthetic. You must
choose the primary procedure you want to include in your log and submit it in the appropriate category.
The other procedures from that “case” can be optionally listed with the primary procedure, to indicate
other work was done, but only the primary procedure is tallied in the category.
For example, you might have repaired flexor tendons and digital nerves in the surgical visit, accounting
for multiple “procedures”. However, you must choose which procedure you want to log, i.e. either flexor
tendon repair or digital nerve repair, and not list them as separate “cases”.
The medical record number, not the account number, should be recorded in the Case # field of the
Surgical Log.
Complications and Outcome
The Complications and Outcome column on the Surgical Log template should be used to record
surgical complications and the outcome of those complications.
If no complications occurred leave this field BLANK.
Listed below are examples of complications that may occur after surgery. Complications may
include but are not limited to this list.
• Infection
• DVT
• Neurovascular compromise
• Wound dehiscence
• Malunion/non-union
• Morbidity
• Mortality (within 30 days of procedure)
• Indication of related cases
The complications and outcome column should also be used to make note of related cases. If there
are multiple cases on different dates for the same patient that are related this should be noted under
Complications and Outcome. This will ensure that your examiner does not select two related cases
for you to prepare for examination with the impression that they are independent cases.
For example, you perform an irrigation and debridement procedure, with application of external
fixation in a single surgical visit (one case). You then return one week later and remove the external
fixator and perform an intramedullary nailing (one case). The two primary procedures, external
fixation and intramedullary nailing would be listed separately, and you should list the other procedure
under the Complications and Outcome for each case.
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Clinic Cases
If you are practicing in a Residency Training Program where you supervise the clinic run by the residents
who perform the procedures and manage care of patients from that clinic, you have the option of
excluding these cases from your log. If you choose to include them, you will be held to the same standard
of participation as expected in the rest of your cases including evidence that you clearly have supervised
the management of these cases.
Mortalities
Mortalities apply to deaths that occur within 30 days of the surgical procedure. All mortalities require
a summary report to be personally authored by the candidate. A Mortality Report template is available
within the clinical application and on the AOBOS website.
This summary should explain in as much detail as necessary:
1. The Orthopedic surgery performed
2. The pre- and post-operative course
3. The cause of death
4. How the surgery affected the mortality
5. Any pertinent lab or x-ray findings
6. The general hospital course
It is up to the Senior Examiner whether or not a mortality case is chosen as one of the twelve (12) cases
for the Individual Chart Survey.
Surgical Log Template
Surgical Logs must be compiled using the Excel template found both on the AOBOS website
(www.aobos.org ) and within the application portal.
The Surgical Log serves as a representative snapshot of your practice. It will provide the pool from which
your senior examiner will select cases for you to prepare for the Clinical Examination. The materials for
all of the cases in your log MUST be available to you to gather for your exam.
This is the required format for the submission of surgical cases. No independent format may be
substituted. No alternate categories may be used. The first worksheet visible in the Excel file is the Log
Summary Sheet.
Enter your name in cell B3 on this form and the beginning and ending dates for your surgical log entry in
cell B5. Once finished entering your surgical log data in the appropriate categories, enter the number of
cases for each category in column B on this worksheet.
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Surgical Log Template Cont’d
A sample of the A1. Arthroscopy – Knee log is displayed below.
Within each category, you must:
1. List the cases chronologically.
2. Number your cases 1 to X separately for EACH category.
A sample log for the category, A1. Arthroscopy – Knee, is listed on the following page.
DOB
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list # date
hospital
case # P.I. Age
Diagnosis Operative Procedure
Complications &
Outcome
1 1/12/2014 LSC 12367890 DKM 22
Tear medial meniscus Left
knee
Scope medial menisectomy left
knee
2 1/15/2014 LSC 12389012 SWQ 27
Tear medial meniscus Left
knee
Scope medial menisectomy left
knee
3 1/17/2014 LSC 12390123 HTF 31
Tear lateral & medial
meniscus Rt knee
Scope medial and lateral
menisectomy rt knee
4 1/17/2014 LSC 12391123 JKU 26
Tear medial meniscus and
ACL left knee
Scope medial menisectomy left
knee, ACL reconstruction B-T0B
allograft
5 1/19/2014 LSC 12400121 TAM 16
Chronic lateral tracking rt
patella
Scope lateral retinacular release rt
knee
6 1/30/2014 LSC 12400245 EWS 18
Tear meidal meniscus Left
knee
Scope medial menisectomy left
knee
7 2/2/2014 LSC 12400345 HGT 27
Tear right ACL
Scope hamstring tendon ACL
reconstruction rt knee
8 2/26/2014 LSC 12431189 FTR 65
Tear medial meniscus Left
knee; djd MFC
Scope medial menisectomy left
knee, chondroplasty medial femoral
condyle
Post op DVT. Admitted for
heparinization. Discharge
in 3 days. Recovered
uneventfully.
9 3/1/2014 LSC 12481190 DGJ 21
Bucket handle tear medial
meniscus rt knee
Scope medial menisectomy rt knee
10 3/4/2014 LSC 12500121 GBI 65
Tear medial and lateral
meniscus rt knee
Scope medial/lateral menisectomy rt
knee
11 4/1/2014 ACH 290-090 ITD 67
Septic Arthritis left knee
Scope irrigation, synovectomy,
insertion of inflow outflow drains left
knee
12 4/4/2014 ACH 290-290 ITD 67
Septic Arthritis left knee Scope, synovectomy left knee
Candidate Name
A1. Arthroscopy-Knee
Laterality should be
indicated. No CPT codes.
Medical Record Number
P.I. = Patient Initials
Example of a
complication and
outcome notation
If there are no
complications, this
field should be blank.
The Complications & Outcome column should also be used
to note related cases. i.e. If related procedures were
performed on the same patient on different dates.
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Step 2 - Examiners are Assigned
Two examiners are assigned to each candidate, a senior and a junior examiner. You will be notified with
the names and contact information of your two examiners after examiner positions are filled. All
examiners are Board Certified and have been trained in the Clinical Examination process. Every attempt
is made to ensure at least one examiner practices the same subspecialty as you.
If you have a conflict with either examiner, contact the AOBOS office immediately so that a replacement
can be found.
Step 3 - Senior Examiner Chooses Charts
The senior examiner is sent the candidate’s surgical log, hospital location sheet, and mortality report (if
applicable). From these documents, twelve (12) cases that represent the candidate’s practice with
varying degrees of complexity are selected and the list is sent to the candidate. (Note: any candidates
remaining in the Historical Exam format will have 20 cases selected and will not have the Case Defense
aspect of the exam.)
Step 4 – Candidate Examination
Once examiners have been assigned a detailed schedule for the cycle will be distributed to candidates
and examiners with deadlines for each portion of the process. Candidates will be given no less than 30
days to prepare the case materials for the selected cases.
Twelve (12) cases are reviewed in great detail by the Senior and Junior examiners. Five (5) of the twelve
(12) are chosen for the case defense interview.
(Note: any candidates remaining in the Historical Exam format will have 20 cases selected and will not
have the Case Defense aspect of the exam.)
For the Case Defense segment, the senior examiner will confer with the junior to find several available
dates and times for the Zoom meeting and present them to the candidate. You will work together to
find a meeting time that works for all parties. You will not know before the interview meeting which 5
cases were chosen and should be ready to discuss any of the 12 cases you have prepared for the
examination. Each case will be discussed for approximately 15 to 20 minutes. This is an opportunity for
the examiners to determine medical decision making and thought processes that may not be readily
evident from the chart review alone.
The Case Defense Zoom call will be scheduled for 2 hours and will be between 1.5 to 2 hours in duration.
Chart Preparation General Guidelines
It is the policy of the AOBOS that there must be clear evidence and written documentation that the
surgeon has evaluated the patient pre-operatively. If the information was gathered as an outpatient or
during an office visit, it is required that the appropriate office records be included in the chart. We are
interested in your preoperative management and your reasoning for choosing surgical treatment.
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You are also being graded on follow-up care, and the examiners will also need to review office
radiographs and office charts. Be sure to include at the very least the most recent radiographs, and all
others associated with a complication or significant event.
You are responsible for documenting the disposition of the case. This includes circumstances such as
transfer out of the geographic area, transfer to a nursing home or extended care facility or no show in
the office. (In the event of a no-show, you must state what action was taken.) This documentation can
be either in the hospital discharge summary or in your office records.
The chart must clearly document the active role the surgeon plays in patient evaluation and treatment.
House officer, Resident or Advanced Practice Providers (NP/PA) notes, only countersigned by the
surgeon, are NOT sufficient and will not be viewed as acceptable as a demonstration of active
management of a patient.
The template for chart material compilation provided to candidates consists of 13 sections. The sections
are listed and described below. The appropriate material compiled in these sections constitutes a
complete chart.
1. Pre-op Evaluation – H&P
• Entire pre-operative office notes denoting the pre-operative workup.
• H&P or pre-operative documentation of the treatment plan authored by the candidate.
Following Medicare guidelines an H&P must be performed no more than 30 days prior to
admission and updated the day before or day of surgery. Office medical records that substantiate
the hospitalization or procedure should be part of the inpatient record. Medicare requires that
the hospital medical record justify the admission and treatment. This should include ALL of the
candidate’s office notes pertaining to the management of the patient leading up to the surgical
procedure.
2. Pre-Operative Imaging and Radiology Reports
• Pre-operative or injury films and all appropriate ancillary studies (CT, MRI, Bone scan etc.).
ALL pertinent pre-op, intra-op and post-operative radiographic studies should be placed into a
Power Point format that is labeled and dated. Images should appear as they would in a PACS
(they should not be distorted).
3. Consent
• Evidence of informed consent. The consent form should reflect the procedure as scheduled,
signed by the patient and the candidate as mandated by the candidates surgical location.
4. Intra-Operative Reports
• Official operative record denoting operative time and blood loss. This should include pertinent
anesthesia and nursing documentation.
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5. Operative Report
• Operative procedure note(s) authored by the candidate.
6. In Patient Progress Notes
• Entire post-operative hospital record as related to the surgical procedure being evaluated. This
should include labs, orders, radiographic studies, post-operative notes, and all progress notes
related to the patient’s care by the candidate, or from other providers consulted regarding
conditions affecting the patient’s management related to the condition or as a result of the
surgery.
7. Consults
• Any consults prior to elective / emergent procedures directly related to the patient’s ability to
undergo the planned procedure, as well as consultations related to conditions that result in a
change of the patient’s plan of care.
8. Post-Op Instructions – Discharge Summary
• All post-operative orders.
• If outpatient surgery, prescription documentation and discharge instructions to the patient.
• Discharge summary or comprehensive discharge note.
9. Arthroscopy Photos
• Color pre and post-intervention pictures.
10. Intraoperative – Postoperative Imaging
• Intra-operative or immediate post-operative radiographs.
• Representative post-operative radiographs to depict follow-up AND final radiographs
demonstrating condition at time of discharge from care.
11. Outpatient Progress Notes – Follow Up
• Post-operative office notes/chart depicting aftercare until discharge from care, or up to the time
of uploading documentation to FileBox for the examination should be included.
12. Physical Therapy
• Notes pertinent to the patient’s pre- or post-operative care.
13. Miscellaneous
• This could include documentation regarding attempts at follow-up for patients lost to care,
follow-up notes from providers/associates the patient may have been referred to for definitive
treatment, or other documents demonstrating or explaining deviations from anticipated
treatment plans.
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Clinic Cases
If you are practicing in a Residency Training Program where you supervise the clinic run by the residents
who perform the procedures and manage care of patients from that clinic, you have the option of
excluding these cases from your log. If you choose to include them, you will be held to the same standard
of participation as expected in the rest of your cases, including evidence that you clearly have supervised
the management of these cases.
Redaction
All identifying patient information must be redacted from the case materials. Redaction can be
accomplished in any manner that works for the candidate as all medical records systems and office notes
are stored differently. Options are search & replace, Adobe redaction feature, or blacking out the
information or covering it before scanning paper files.
Chart Review Grading (Please see the rubric for greater detail)
1. Pre-Operative Care & Evaluation
2. Chart Mechanics:
a. H&P/Consults/Progress Notes
b. Operative Consent
c. Operative Report/Discharge Summary/Orthopedic Post-Op Instructions.
3. Indications for Surgery
4. Performance of Surgical Procedure
5. Quality of Follow-Up Care
6. Holistic Impression
Case Defense
For New Format candidates the senior examiner will contact you with several possible dates/times that
work for the senior and junior examiner to find a date/time that works for you. The senior examiner will
communicate the final decided upon date/time to AOBOS who will schedule the Zoom meeting and send
invitations to all parties. The case defense meeting will be scheduled for 2-hours to provide cushion for
any delays but should last for approximately 90 minutes.
The 5 cases to be discussed will be relayed to you at the start of the meeting. You should be prepared to
discuss any of the 12 cases that you prepared.
The meeting will begin with you giving a brief summary of the case followed by questions from the
examiners. You should be connected to your fileshare site or have downloaded your cases to your local
drive and be prepared to share your screen to review chart materials particularly imaging to illustrate the
diagnosis, treatment, and outcome.
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Case Defense Grading (Please see the rubric for greater detail)
1. Patient Presentation, Relevant History
2. Interpretation of Studies - *Only studies submitted with case materials for chart review can be
considered during the Case Defense interview. New studies may not be introduced during the Oral
Case Defense interview.
3. Medical Knowledge
4. Medical Decision Making
5. Post-Op Protocol / Outcomes
Step 5 – Scores are Determined
Following the exam, the examiners will submit their evaluations. They will not be able to tell you if have
or have not passed the exam. The evaluations will then undergo a statistical analysis by a
psychometrician. The scaled scores will be submitted to the Board for review.
Grades will be posted for candidates within 12 weeks of the examiner grade submission deadline. AOBOS
staff will email all candidates with login instructions when grades are available.
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FOR EXAMINERS
INTRODUCTION
The AOBOS utilizes a scoring method for the Clinical Exam where examiners score candidates in multiple
predetermined areas.
The scoring will be derived from an in-depth review of 12 charts from the candidate’s surgical log and a
case defense interview for 5 of those 12 charts. (Note: there are a small number of candidates who are
grandfathered into the Historical Clinical Exam format, this is a review of 20 charts with no case defense
interview. The Historical Format will retire as of 12/31/2024) The format of the exam is noted with the
candidate information.
EXAM PROTOCOL
These are the basic steps in the Clinical Exam Process:
Step 1 - Application Process (Candidate)
Candidate submits Application, Payment, Surgical Log, and Mortality Report, if applicable.
Step 2 - Log Approval (Board)
AOBOS staff reviews application and Surgical Log for completeness. AOBOS Board reviews the Surgical
Log and Mortality Report, if applicable, and makes approval determination.
Step 3 - Examiners Assignments
(AOBOS Staff and Examiner Volunteers)
The AOBOS staff will solicit trained examiner volunteers to perform exams. After Senior and Junior
examiner assignments are completed, candidates and examiners will be sent notifications, materials, and
a detailed timeline for the exam cycle.
Step 4 - Chart Selection and Communication to Candidate
(Senior Examiner)
The senior examiner will review the candidate’s surgical log and mortality review report (if applicable)
and select the cases for the candidate to prepare for examination. 20 for Historical Format candidates
and 12 for New Format candidates. The senior examiner may consult with the junior examiner in
selecting cases for review. See the section on selection charts for review for specific guidelines.
Time allotted is approximately 12 days.
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Step 5 - Chart Preparation and upload (Candidate)
Candidates compile all materials for each selected case into the required template provided to them and
upload materials into the secure fileshare which will be shared with examiners.
Time allotted is approximately 30-35 days.
Step 6 - Examiner Chart Review, Case Defense or Exit Interview Zoom
Meeting (Sr. and Jr. Examiners plus Candidate for Meeting)
a. Examiners are sent access to the secure fileshare where candidate materials are stored.
b. Examiners review each case and enter scores in the online scoring form.
c. The Senior examiner coordinates a date/time with the junior and candidate for the Case
Defense interview (New Format) or the Exit Interview (Historical Format).
d. The senior examiner relates the selected date/time to AOBOS staff and staff creates the Zoom
and sends invitations to all parties.
e. Examiners and candidates participate in Zoom meetings.
f. Examiners enter Case Defense scoring for New Format exams in the online scoring form.
g. Examiners submit final scoring by the designated due date.
Time allotted is approximately 55 days.
Step 7 - Scores are Determined (AOBOS)
At the end of the clinical examination cycle, all scores for each exam conducted are compiled and sent to
the psychometrician for evaluation. The psychometric report, examiner letters and evaluation forms are
reviewed by the Board. Candidate result letters and score reports are posted within 12 weeks of the
examiner grade submission deadline.
RESPONSIBILITIES
Senior Examiner
1. The senior examiner plays a crucial role in the exam process by performing the following:
2. Volunteer for the exam. Ensure the absence of any personal or professional conflicts with the
candidate. This includes a prior relationship, (such as previous partner, or student/resident) or
practice conflicts (too close geographically, litigation etc.).
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3. Review logs and mortality review report sent via email by AOBOS staff.
4. Selects cases for the exam. The senior examiner may consult with the junior examiner in selecting
the cases for review.
5. Schedule and conduct the Zoom meeting, by coordinating with the junior examiner and
candidate.
Collaborate with the junior examiner to select the 5 cases for review during the Oral Case Defense
Zoom interview.
6. Utilize the online grade entry to enter grades.
Junior Examiner
1. Volunteer for the exam. Ensure the absence of any personal or professional conflicts with the
candidate. This includes a prior relationship, (such as previous partner, or student/resident) or
practice conflicts (too close geographically, litigation etc.).
2. Communicate directly with the senior examiner regarding the examination.
3. Consult with the senior examiner about case selection if requested.
4. Work with the senior to find a time for the Zoom Case Defense (New Format) or Exit Interview
(Historical Format) and participate in the meeting.
Collaborate with the senior examiner to select the 5 cases for review during the Oral Case
Defense Zoom interview.
5. Utilize the online grade entry to enter grades.
GUIDELINES FOR SELECTING CASES FOR CHART REVIEW
1. Select cases that represent a broad inspection of the candidate’s scope of practice. There will be
20 cases selected for Historical Format exams which are chart review only and 12 cases selected
for New Format exams which are chart review and case defense.
2. The selected cases should be of sufficient scope to include fracture management, trauma,
arthroscopy, joint replacement, adult diseases. Subspecialty exams should select cases across a
spectrum of pathology.
3. When selecting cases of similar type, such as ankle fractures, it is recommended to select cases
from varying times over the course of the log. For example, selecting three ankle fractures, one
from the early log, one from mid log and one from the end of the log provides examiners a
longitudinal look at the candidate’s work.
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4. Some complicated cases should be reviewed to evaluate the candidate’s management of
complex cases. However, it is inappropriate to select all complicated cases.
5. Be cognizant of related cases. Two cases for procedures performed on the same patient that are
related should not be selected as independent cases for review due to the overlap in pre-
operative workup and follow up.
6. Both examiners review the same cases and score them independently.
7. Cases should be selected at communicated to the candidate by to stated deadline to allow the
candidate the same preparation period as all other candidates in the testing cohort.
SUBSPECIALTY ORTHOPEDIC SURGEONS
If the candidate’s practice is predominantly in a subspecialty, e.g. spine, hand, pediatrics, etc., you must
keep in mind you are still recommending them for certification as an Orthopedic Surgeon.
Whatever the subspecialty may be, the Board will make every attempt possible to arrange one of the
examiners to have a similar subspecialty, provided the candidate informed the Board of their
subspecialty.
CHART REVIEW
The candidate must show they are managing the case, not necessarily authoring and dictating
all notes. Candidates must clearly document their active role in patient evaluation and
treatment.
Following Medicare guidelines:
An H&P must be performed no more than 30 days prior to admission and updated the day before
or day of surgery. Office medical records that substantiate the hospitalization or procedure
should be part of the inpatient record. Medicare requires that the hospital medical record justify
the admission and treatment.
Discharge summaries should be dictated as soon as possible after discharge. If unable to dictate
on the day of discharge, write a final summarizing progress note to include:
1. Principal diagnosis, secondary diagnoses and principal procedure.
2. Brief description of the hospitalization, disposition of the case, and follow-up care.
3. Results of diagnostic testing that confirm the principal diagnosis.
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Chart Review Grading
The individual charts are to be reviewed in detail. In evaluating each of the components follow
the Chart Review Scoring Rubric.
The following instructions are provided to give a better explanation of each area.
The grading form provides a comment section for each grading point. Additional comments are
welcome for Superior and Satisfactory grades and required for Marginal and Unsatisfactory
grades.
Pre Operative Care & Evaluation
This includes documentation of conservative care, proper work-up including appropriate
diagnostic studies, consultations when necessary, and clear evidence the candidate is personally
managing the case.
Chart Mechanics
To be acceptable, each area must:
▪ Be present
▪ Contain the appropriate information
▪ Provide documentation authored by the candidate clearly documenting the active role the
candidate plays in patient evaluation and treatment
The history and physical and/or pre-operative evaluation may be part of the outpatient record.
Progress notes are not required daily if the candidate’s practice situation has coverage by other
orthopedic surgeons. Other provider notes, which are countersigned ONLY, are still not
acceptable. However, if any untoward event occurs or change in normal post-operative
management is required, the candidate must document this fact on the record.
Operative reports must be performed by the candidates.
Discharge summaries should be added by the candidate; however, a written discharge note that
outlines the post discharge plan is acceptable. A check form signed by the candidate is not
acceptable.
Indications for Surgery
In your judgment, was the surgery, as performed, indicated? Was the appropriate surgery
chosen?
Performance of Surgical Procedure
Was the surgery performed competently? This may include operative time, blood loss,
complications, and especially, review of the post-operative images.
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Quality of Follow-Up Care
We ask you to review the entire patient course, including the post operative follow-up care.
Therefore, it is necessary for you to review the candidate’s office records and follow-up images.
The most recent films should be reviewed, along with any interim films as necessary.
The scoring is based on appropriate follow up care. Some areas to consider include:
▪ Was the patient seen back in a timely manner?
▪ Were all post-operative complications acknowledged and treated appropriately?
▪ Was rehab provided when needed?
▪ Was the final result as expected?
The candidate is responsible for documenting the disposition of the case. This includes
circumstances such as transfer out of the geographic area, transfer to a nursing home or extended
care facility or simply a no show in the office. This documentation can be either in the hospital
discharge summary or in the candidate’s office records.
Holistic Impression
Your overall professional evaluation of the candidate's performance of the case reviewed. You
will provide a Holistic Impression for each case in the chart review portion of the exam.
Post Observation Letter to the Board
Please use this area to explain deficiencies or problematic areas.
It is critical the Board have this information, especially in the case of an exam failure.
It is also useful to report extremely high performing candidates that are potential future
examiners.
Chart Review – Mortality Review
All mortalities must be reported in the candidate’s surgical log. In addition to indicating the mortality in
the log candidates must provide a mortality report. Mortalities apply to deaths that occur within 30
days of the surgical procedure.
It is up to the Senior Examiner whether or not a mortality case is chosen as one of the cases for review.
The Mortality Report should explain in as much detail as necessary:
1. The orthopedic surgery performed
2. The pre and post operative course
3. The cause of death
4. How the surgery affected the mortality
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5. Any pertinent lab or x-ray findings
6. The general hospital course
CASE DEFENSE
For new format examinations a case defense interview will be conducted to discuss in more depth a
subset of the cases selected for chart review. The case defense will occur after both examiners have fully
reviewed the chart materials for all 12 cases. The senior and junior examiner should discuss which 5
cases should be selected for case defense. The candidate should be prepared to discuss any of the 12
cases. The 5 cases for defense should be relayed to the candidate ONLY at the start of the Zoom case
defense meeting.
The case defense meeting should begin with informing the candidate which 5 cases were selected. The
candidate should be given the opportunity to present a summary of the case followed by questions from
the examiners.
The Case Defense Zoom will be scheduled for 2 hours to provide a buffer but should be closer to 1.5
hours in duration.
Case Defense Grading
The case defense focuses on 5 components. See the Clinical Case Defense Scoring Rubric for a detailed
scoring breakdown.
In the grading form there is a comment section provided for each grading point. Please utilize this section
particularly when assigning a marginal or unsatisfactory rating.
Patient Presentation, Relevant History
Evaluation of the candidate’s explanation of the patient presentation, complaint, diagnosis, and relevant
history.
Interpretation of Studies
*Only studies submitted with case materials for review can be considered during the Case Defense
interview.
Evaluation of the candidate’s description of the studies performed.
Medical Knowledge
Evaluation of the candidates understanding of the classification systems and natural history of the
disease.
Medical Decision Making
Evaluation of the candidate’s description of the surgical plan including awareness of complications,
treatment options, and efficiency.
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Post-Op Protocol / Outcomes
Evaluation of candidate’s description of post-operative follow up, patient recovery.
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FOR CANDIDATES AND EXAMINERS
RUBRICS
AOBOS Clinical Chart Review Scoring Rubric
Unsatisfactory
1
Marginal
2
Satisfactory
3
Superior
4
Pre-operative Care &
Evaluation
Inadequate or no work-up
to establish a diagnosis.
Studies ordered do not
support the diagnosis.
Poor documentation of
history and physical exam
findings. Limited or no
attempt at conservative
care, when indicated
Incomplete work-up.
Limited documentation of
history and physical exam
findings such that the
diagnosis is unclear.
Conservative care
documented when
indicated, but of
insufficient duration or
type.
Documentation supports
the diagnosis and
treatment plan. Proper
ancillary studies available
and interpretations
documented. Appropriate
type and duration of
conservative care.
Documentation supports
the diagnosis and
treatment plan and
considers differential
diagnosis. Correct
ancillary studies available
with complete
documentation of findings
and significance. Proper
conservative care
documented with
consideration of
alternatives.
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Unsatisfactory
1
Marginal
2
Satisfactory
3
Superior
4
Chart Mechanics:
H&P/Consults/
Progress Notes
Inadequate or no
documentation to
establish diagnosis.
Studies ordered do not
support the diagnosis.
Poor documentation of
history and physical exam
findings. Very limited or
no objective finding.
Indicated consults not
done or not documented.
Notes not done by the
surgeon. Complications
not discussed or
documented.
Limited documentation of
history and physical exam
findings such that the
diagnosis is unclear.
Limited documentation by
the surgeon (i.e. most
documentation is
authored by ancillary
staff). Insufficient
consultation
documentation.
Incomplete progress
notes. Incomplete
documentation of
complications.
Documentation supports
the diagnosis and
treatment plan. Proper
ancillary studies available
and interpretations are
documented. Notes
authored by the surgeon
that are appropriate and
complete with objective
findings. Complications
and plans of treatment are
clearly documented.
Documentation supports
the diagnosis and
treatment plan and
considers differential
diagnosis. Correct
ancillary studies available
with complete
documentation of findings
and significance.
Complications are
identified and
documented by surgeon
with treatment plan.
Chart Mechanics:
Operative Consent
Office notes do not
document pre-operative
discussion of the planned
procedure, risks and
benefits of the procedure.
Surgical permit
incomplete or inadequate
description of planned
procedure.
Office notes document
incomplete pre-operative
discussion of the planned
procedure, risks and
benefits of the procedure.
Surgical permit meets
minimum required
description of treatment
plan.
Office notes document
complete pre-operative
discussion of the planned
procedure, risks and
benefits of the procedure.
Surgical permit clearly
describes treatment plan
and risks.
Office notes document
complete pre-operative
discussion of the planned
procedure, risks and
benefits of the procedure,
and alternative
treatments with rationale
for decision making.
Surgical permit clearly
describes treatment plan
and risks.
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Unsatisfactory
1
Marginal
2
Satisfactory
3
Superior
4
Chart Mechanics:
Operative
Report/Discharge
Summary/Post-Op
Instructions
Documents incomplete or
not present. Documents
do not contain required
information. Insufficient
description of procedure.
Inaccurate description of
procedure. (i.e. – x-ray
findings do not match
operative report)
Documents minimum
requirements only.
Incomplete description of
procedure.
Clearly and accurately
documents complete
procedure. Discharge
instructions complete and
appropriate for procedure
and diagnosis.
Clearly and accurately
documents complete
procedure. Documents
include indications for
procedure, operative
findings, and all pertinent
facts. Discharge
instructions are complete
and appropriate for
procedure and diagnosis
including restrictions,
therapy, and follow-up
plan.
Indications for Surgery
No documentation of
indications for the
procedure. Clear
documentation of
contraindications for the
planned procedure.
Planned procedure
inappropriate for the
clinical situation.
Indications for the
procedure are
questionable. More
information needed to
justify surgical plan.
Procedure may be
indicated, but
documentation does not
clearly support the plan.
Surgical procedure is
appropriate for the clinical
situation and
documentation supports
the diagnosis and surgical
plan.
Modification of the
surgical plan reflects high
level of knowledge and
experience in avoiding
complications while
simplifying the treatment
approach. Mature
judgement is reflected in
the plan.
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Unsatisfactory
1
Marginal
2
Satisfactory
3
Superior
4
Performance of Surgical
Procedure
Technical mistakes
compromise the outcome
of the case. Dangerous
practice observed that is
likely to lead to
complications. Failure to
recognize and treat
pathology. Clearly failing
candidate.
Technical errors observed.
Completes case but
Borderline failing
candidate.
Completes case
appropriately with
minimal error. Errors that
occur are recognized and
addressed appropriately.
Proceeds with reasonable
efficiency. Passing
candidate.
No technical errors occur.
Very time efficient.
Proceeds with confidence
and great skill. Clearly
excellent surgeon.
Quality of Follow-Up
Care
No, or incomplete, follow-
up. Lost to follow-up with
no documentation of
patient. Failure to
recognize and/or treat a
complication. Patient
discharged from care at
inappropriate time.
Follow-up incomplete or
not clearly documented.
Failure to completely
recognize and/or treat a
complication. Errors in
post-surgical
management.
Appropriate follow-up and
management. Recognizes
and treats problems in a
timely manner. Follows
patients for reasonable
time post-operatively.
Unsuccessful attempts to
reach the patient are
acceptable if documented.
Excellent documentation
of follow-up. Appropriate
decision making.
Recognizes problems early
and adjusts treatment as
indicated. Clearly
excellent management.
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Unsatisfactory
1
Marginal
2
Satisfactory
3
Superior
4
Holistic Impression
Your overall professional
evaluation of the
candidate's performance for
the chart reviewed,
including the candidate’s
logic, fundamental
understanding and
professional judgment.
Poor insight; fails to
formulate correct
diagnosis; misinterprets
data; incorrectly evaluates
and manages problems;
frequent incomplete or
missing documentation;
poor decision making.
Limited insight;
questionable decision
making; minimum
knowledge; management
and technique falls below
reasonable standards;
incomplete
documentation to support
medical decision making.
Sufficient knowledge;
moderately capable;
acceptable assessment
capabilities; room for
improvement. Makes
reasonable management
and treatment decisions;
accurate and complete
critical documentation;
reasonable technical
execution of treatment
plan.
Clear and concise
comprehension; correct
decision making without
any errors; can work
through entire case
management with no
issues at all; demonstrates
advanced knowledge;
excellent complete
documentation of medical
decision making; excellent
technical execution of
treatment plan.
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AOBOS Clinical Case Defense Scoring Rubric
Unsatisfactory
1
Marginal
2
Satisfactory
3
Superior
4
Patient Presentation,
Relevant History
Candidates’ summary
describing the patient
presentation, complaint,
diagnosis, and relevant history
is insufficient.
Candidates’ summary
describing the patient
presentation, complaint,
diagnosis, and relevant history
lacks detail.
Candidates’ summary describes
the patient presentation,
complaint, diagnosis, and
relevant history in satisfactory
detail.
Candidates’ summary describes
the patient presentation,
complaint, diagnosis, and
relevant history in great detail.
Interpretation of
Studies
*Only studies submitted with
case materials for review can
be considered during the Case
Defense interview.
Candidate describes studies
performed. Studies are
inaccurate or have not been
submitted. Candidate’s
understanding of the workup is
unacceptable.
Candidate describes studies
performed. Studies are
insufficient but not inaccurate.
Candidate displays limited
understanding of the workup.
Candidate describes studies
performed adequately. Studies
are appropriate. Candidate
displays reasonable
understanding of the workup
and has included the gold
standard test.
Candidate describes studies
performed completely. Studies
are appropriate. Candidate
displays full understanding of
the workup and has included
the gold standard test.
Medical Knowledge
Candidate’s understanding of
classification systems and
natural history of disease is
insufficient.
Candidate’s understanding of
classification systems and
natural history of disease is
marginal.
Candidate’s understanding of
classification systems and
natural history of disease is
satisfactory.
Candidate’s shows complete
understanding of classification
systems and natural history of
disease.
Medical Decision
Making
Description of surgical plan
that is inappropriate for the
clinical situation. Technical
mistakes compromise the
outcome of the case and could
lead to complications.
Description of surgical plan is
inadequate. Shows insufficient
awareness of complications.
Errors occur that are not
addressed with the appropriate
technique.
Description of the surgical plan
is appropriate for the clinical
situation. Shows satisfactory
awareness of complications.
Minimal errors that are
recognized and addressed
appropriately. Reasonable
efficiency. Candidate has
awareness of different
treatment options.
Description of the surgical plan
reflects high level of knowledge
and experience in avoiding
complications while simplifying
the treatment approach. No
technical errors occur. Very
time efficient. Candidate has
full awareness of different
treatment options.
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Unsatisfactory
1
Marginal
2
Satisfactory
3
Superior
4
Post-Op Protocol /
Outcomes
Candidate describes
incomplete or no post-
operative management.
Patient is lost to follow-up with
no attempts to contact Failure
to recognize and/or treat a
complication. Patient
discharged from care at
inappropriate time.
Candidate describes sub-
optimal objective measures of
patient recovery at follow-up.
Fails to completely treat a
complication. Errors in post-
surgical management. Follows
patient for insufficient period.
Candidate describes generally
appropriate objective
measures of patient recovery
at follow-up. Recognizes and
treats problems in a timely
manner. Follows patients for
reasonable period.
Candidate describes
appropriate objective
measures of patient recovery
at follow-up. Recognizes
problems early and adjusts
treatment as indicated. Follows
patient for the appropriate
period.
