Case List Instructions

Adding cases to Scribe when applying to take a Part II examination

 

Accessing Your Case List

• Go to www.abos.org and log in to your ABOS Candidate Dashboard.
• Before registering patients, please add all the hospitals/surgery centers in which you perform surgical procedures. To do so, click on the Scribe Case List Tool link. You will then be brought to the Scribe Case List System home page. Click the Add Hospital link to ADD THE HOSPITALS IN WHICH YOU OPERATE. These hospitals/surgery centers will then be available for selection when registering patients.
• To register patients for ABOS Case Collection, go to https://www.abos.org/p (note ” / p”), and login with the username and password displayed on your ABOS Candidate Dashboard. You may distribute this login information to surgical schedulers or staff who may be registering patients for you. REGISTER PATIENTS PREOPERATIVELY OR PERIOPERATIVELY. If you begin registering patients before you have entered your hospitals, then you may select “Other” as the hospital when registering patients — you will be able to change the hospital selection for each patient later in Scribe once you have added the appropriate hospital.
• YOU MUST ENTER ALL CONSECUTIVE SURGICAL CASES FROM ALL HOSPITALS/SURGERY CENTERS IN WHICH YOU OPERATE DURING YOUR ENTIRE CASE COLLECTION PERIOD. Every time you take a case to the operating room as the primary surgeon (not as a co-surgeon or an assistant surgeon), you must add a new case and complete the entire page, even if the reason you take the patient to the operating room for a second time is a complication to the first case already submitted.
• After operating on a patient, return to the Scribe Case List System by clicking the Scribe Case List Tool link from your ABOS Candidate Dashboard to enter the information about the case. Be sure to review and update follow-up/complication/re-operation/re-admission information near the end of the collection period. YOU ALONE ARE RESPONSIBLE FOR THE ACCURACY AND COMPLETENESS OF YOUR CASE LIST DATA. ALL CASES MUST BE COMPLETE (EVERY REQUIRED FIELD FOR THE CASE COMPLETED) IN ORDER FOR YOUR CASE LIST TO BE ABLE TO BE SUBMITTED.

Entering a New Case

• From https://www.abos.org/p, login with your assigned patient registration username and password, which can be found on your ABOS Candidate Dashboard, and complete and submit a patient registration form.

Completing a Case

• Log in to your ABOS Candidate Dashboard at https://www.abos.org, click the Scribe Case List Tool link, and click on the case of a patient who has been registered. Enter patient information in ALL fields. If all fields are not completed, the case will appear in the Incomplete Cases List until all fields are complete. You will not be able to finalize your case list until all cases are completed.
• Enter Patient Initials: Only enter the initials of the patient. Do not enter the full name of the patient.
• Enter Patient ID: Use the same patient ID as the hospital’s medical record ID for all procedures. This ID allows the Medical Records Director to cross-reference the cases you input into Scribe with their records at the hospital for verification. Do not use full social security numbers to protect patient confidentiality.
• Enter Patient’s Age: Patient’s age on the date of the surgery in years.
• Select Patient Sex: Male/Female.
• Enter Date of Surgery/Treatment: This is the date that the surgery was performed.
• Enter Diagnosis (ICD-9/ICD-10) Code: Only one code is required. If multiple diagnoses apply for the same operating room setting, enter each code. Enter the primary diagnosis first.
• Enter Treatment (CPT) Code: Only one code is required. If multiple procedures were performed during the same operating room setting, enter each code. Enter the primary procedure first.
• Select Anatomic Region: Select the anatomic region on which the surgery was performed. If multiple anatomic regions were operated on during the same operating room setting, select the primary one.
• Enter Date of Last Follow-up: Enter the date of the last follow-up with the patient. This is the last date you saw the patient before you finalize your case list.
• Enter Description of Operation: In 100 characters or fewer, briefly describe the operation only. Do not include any patient history or patient identifiable information.
• Select Anesthetic Complications: If there were anesthetic complications, select each complication that applies, and classify the severity of each complication using the dropdown menu. If there were no anesthetic complications, select “No Anesthetic Complications”
• Select Surgical/Technical Complications: If there were surgical/technical complications, select each complication that applies and classify the severity of each complication using the dropdown menu, and you must enter a description in the Explanation of Complication field. If there were no surgical/technical complications, select “No Surgical Complications”.
• Select Medical/Systemic Complications: If there were medical/systemic complications, select each complication that applies, classify the severity of each complication using the dropdown menu, and you must enter a description in the Explanation of Complication field. If there were no medical/systemic complications, select “No Medical Complications”.
• Select Unexpected Re-Operation: If there was an unexpected re-operation within 90 days of the date of surgery, select “Yes”, and you must enter a description in the Explanation of unexpected re-operation field. If there was no unexpected re-operation within 90 days, select “No”.
• Select Unexpected Re-Admission: If there was an unexpected re-admission within 90 days of the date of surgery, select “Yes” and you must enter a description in the Explanation of unexpected re-admission field. If there was no unexpected re-admission within 90 days, select “No”.
• Reset: This will clear all fields of data entered so you may start over.
• Save Case: This allows you to save the information entered for each case. If the case is not completed at this time, you may go back to the case and enter missing information.
• Complete Case: All information has been entered for this case.

Incomplete Cases

• Incomplete cases always appear on the Scribe home page.
• Cases can be completed by clicking on the Scribe Case # of the case and entering the missing information.
• ALL cases entered must be complete before the list can be finalized.

Editing/Completing a Case by Hospital

• Click the “Edit” tab.
• Select the hospital where the case was performed.
• A list of all cases for that hospital will be displayed.
• Case list can be sorted by Scribe Case #, Patient ID, or Date of Surgery by clicking the corresponding header at the top of the case list.
• Click on a “Scribe Case #” to edit the case information.
• A case to be edited can also be found by searching as described below.

Searching for a Case

• On any page in the Scribe Case List, cases can be searched by Patient ID, Hospital Name, and/or Surgery Date.
• A list of all cases matching the search criteria entered will be displayed.
• Each case may be viewed and/or edited by clicking the “Scribe Case #”.

Print Case Lists

• Print your case list for each hospital after all cases have been entered and completed to review the information entered prior to finalization.
• Counts of complications reported will appear at the bottom of each case list.
• Select the “Print Cases” tab.
• Click the hospital corresponding to the case list you would like to print.
• Case lists will open in Adobe Acrobat Reader, which must be installed on your computer, to view the case list.

Finalization

• Once all information has been entered and verified to be correct, the case list can be finalized. Case lists with incomplete cases cannot be finalized. (Every required field must be completed.)
• Select the “Finalize List” tab.

Submission

• Once you have finalized your case list in Scribe, click on the “Print Case List for Signature” link and take this list to the appropriate hospital’s Medical Records Director for verification. The Medical Records Director is to verify that those surgeries were performed by you as the primary surgeon (not as a co-surgeon or an assistant surgeon) at their facility and that the list is comprised of all the consecutive surgeries performed by you as the primary surgeon at the facility during the case collection period. Once the cases have been verified, they must sign the appropriate place on the signature page of the finalized list, the signature must be witnessed, and your signature is required in the appropriate place on the signature page.
• After all signatures are complete, you will need to scan the completed signature page to your computer. You must upload this page in .pdf format into your Scribe case list. Log in to your Candidate Dashboard and then the “Scribe Case List Tool” link on the left side of the page. Beside the appropriate hospital and/or surgery center name, click on the “View/Upload” button. When the browser screen appears, click on “Browse” and find the applicable scanned copy of the signature page with signatures on your computer, select this signature page file, and click “Upload”. This process will import the signature page into your Scribe case list. You must do this for EACH hospital/surgery center. This process MUST be completed by the deadline.
• If you are on staff at a hospital/surgery center and did not perform any surgeries at this facility during the collection period, you need to upload a letter from the Medical Records Director stating no surgeries were performed during the collection period into the Scribe Case List Tool.

Help/Technical Support

• If you are having technical/computer problems, contact technical support well before the August 15 deadline.
• Email techsupport@abos.org with you name, contact information, and a description of any technical issues you may experience.
• Reach technical support by phone at (919) 822-8028.
• “Contact Info” and “Tech Support” buttons are listed on the bottom of every page of the Scribe system.