Assessment of surgical skills is important in determining that students and postgraduate trainees have achieved the required level of competence. The choice of assessment type should be appropriate to the skill, career stage and area of work. Assessments also drive learning, enhance preparation for clinical workplacements or the next stage of residency training, and can be used as opportunities for feedback and reflection. A lot of time and effort is invested in setting up and running assessments and in making the decisions that ultimately lead to a student being allowed to graduate or a resident achieving specialization status. There are several relevant pedagogical frameworks and a growing evidence-based that can be used by those involved in all aspects of assessment and can guide the choice of assessment methods. The frameworks include Bloom’s taxonomy, Biggs’ constructive alignment, and Miller’s pyramid, which was designed to provide a structured approach to assessment in medical education. There are also factors that influence the utility of an assessment, including reliability, validity, educational impact, acceptability, and feasibility. These inform the selection and implementation of a particular assessment method. For surgical skills, Miller’s pyramid is particularly useful when creating a comprehensive assessment program. Initially the underpinning cognition needs to be learned and assessed (the ‘knows’ and ‘knows how’ of Miller’s pyramid). This is followed by the behavioural components, which are divided into two levels. Firstly, at Miller’s ‘shows’ level, the student is tested using an objective structured clinical examination (OSCE). Ultimately, at Miller’s ‘does’ level, performance is assessed in the clinical environment using workplace-based assessment tools (WBAs). In summary, there are useful frameworks and a growing body of evidence to help ensure the design and implementation of assessments for surgical skills are valid, reliable and demonstrate the achievement of competences.