Training

How to log your ACGME cases without falling behind

The orthobro · 2026-08-26 · 6 min read

Nobody finishes residency short on hip fractures because they never scrubbed a hip fracture.

They finish short because there was a stretch — a trauma block, a bad rotation, a month where everything else was on fire — where nothing got logged. Then the backlog got large enough to be intimidating, then it got old enough that the details were gone, and what eventually got entered was a reconstruction from the schedule rather than a record of what happened.

This is not a rare failure. The ACGME's own Review Committee for Orthopaedic Surgery describes case logging accuracy as poor in many instances, citing a published study of variability in how orthopaedic residents actually use the system.

So the goal is not a better spreadsheet. It is a system with a short enough loop that a bad month cannot destroy it.

First: the rules changed in your favour

Worth knowing, because a lot of the advice floating around is calibrated to the old system.

The old rules required designating primary and secondary codes. That created an incentive to deconstruct a case into parts so that the parts would count — the Review Committee said so explicitly, describing ambiguity for residents and an incentive to break cases up.

The new system removes that. There is no primary/secondary designation, multiple CPT codes can count in one case entry, and there are fewer checkboxes. The anatomic minimums are deliberately broad so that most of what a program does earns credit.

The behaviour this asks for is the simple one: log the whole case, with every relevant code, once. No decisions about how to split it. If you learned to game the old system, unlearn that — it now costs you accuracy and buys you nothing.

The other structural change: from July 1, 2025, the ABOS KSB+ platform interfaces with the ACGME ADS Case Log System for all residents. You log the encounter in KSB+ and the codes transfer to ADS within a few business days.

The actual system

Three rules. That is the whole thing.

1. Codes go in the same day, before you leave the hospital.

Not that night. Not the weekend. Before you leave, while you can still see the case.

This is the only rule that matters, and it is the only one people break. Everything else on this page is downstream of it.

The reason it has to be same-day is specific: the thing that decays fastest is not what operation happened — that is on the schedule — it is your role. Did you do the approach or hold the retractor. Did you do the reduction or watch it. Did you close. Six weeks later you will genuinely not know, and you will pick the answer that is convenient, and that is how logs become fiction.

2. Capture the case in under sixty seconds.

If logging takes ten minutes, you will not do it on the day you most need to. So the same-day capture is deliberately minimal:

• Procedure
• Every CPT code that applies
• Your role
• Supervising attending
• Date and site

That is it. Sixty seconds. Anything richer than that is a different task with a different deadline.

3. Everything else happens in the evening, and it is optional.

The technique note, the thing the attending corrected, the sequence they used, what you want to do differently — all of that is valuable and none of it is compliance. Keep it separate. If you tie your reflective notes to your compliance entry, you will skip both on the days you are tired, and the compliance one is the one with a deadline attached.

Check your totals monthly, not annually

Set a recurring thirty minutes, once a month, to look at where you actually are against the minimums.

You are looking for two things:

Trajectory, not totals. Divide the remaining minimum by the months left. If you need 50 primary TKAs and you are two years out with eleven, that is a conversation now, not a crisis in your chief year.

The small ones. The two new minimums — emergent amputation and emergent fasciotomy, five each — and the low-volume areas like spine at 50 and oncology at 25. These are the ones that go wrong, because they cannot be fixed by ordinary volume. They depend on a specific rotation going a specific way, and finding out you are short in month 55 of 60 leaves you no moves.

Meanwhile femur/knee at 300 and pelvis/hip at 285 usually take care of themselves. Do not spend your monthly check reassuring yourself about those.

Full numbers are on the ACGME case log minimums page.

When you are already behind

You will be at some point. The recovery is not heroic, it is just ordered:

1. Stop the bleeding first. Start logging today's cases today, before touching the backlog. Otherwise the backlog grows while you clear it and you never catch up.

2. Work backwards, newest first. Recent cases are the ones you can still log honestly. Start with the oldest and you spend your energy on the entries you are least able to get right.

3. Use the OR schedule as a prompt, not as the record. It tells you what happened. It does not tell you your role, and your role is the field you are most tempted to inflate.

4. Where you genuinely cannot remember, say so. Log conservatively. An honest log that is slightly under is a problem you can solve with cases. A dishonest one is a different category of problem entirely.

The part that is not about compliance

There is a reason to do this beyond the minimums, and it only pays off if you have been logging honestly.

A log you trust is the only record you have of what you can actually do. Four years in, "how many of these have I done, and how many did I do the important part of" is a question you will want answered — before a fellowship interview, before asking for more responsibility, before deciding what you are good at.

A log you reconstructed from schedules cannot answer that. A log you wrote down on the day can.

That is the whole argument for sixty seconds before you leave.