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ORIGINAL CONTRIBUTION |
From the Chicago College of Osteopathic Medicine at Midwestern University in Downers Grove, Ill (Sleszynski, Glonek) and the Kirksville College of Osteopathic Medicine in Mo (Kuchera).
Address correspondence to Sandra L. Sleszynski, DO, Crossroads Premiere Health Care, SC, 1010 35th St, Kenosha, WI 53140.E-mail: sandrasleszynski{at}crossroadsphc.com
The authors validate the Outpatient Osteopathic SOS (Single Organ System)
Musculoskeletal Exam Form (SOS MSEF), a 1-page form contained within the
4-page Outpatient Osteopathic Single Organ System Musculoskeletal Exam Form
Series (SOS-FS). Handwritten physician progress notes (PPNs) in the medical
record (considered to be the "gold standard" for clinical records)
were compared with information placed on the SOS MSEF for the same patient
encounter. Data recorded by 14 trained and certified investigators on the
standardized SOS MSEFwhich was designed for use with the previously
validated Outpatient Osteopathic SOAP (Subjective, Objective, Assessment,
Plan) Note Form (SNF)was compared with data recorded by the same
investigators in PPNs. The authors compared the accuracy and efficiency of
physicians recording musculoskeletal information in these two formats for 165
patient encounters. Descriptive statistics and t tests were used to compare
data recorded after patient encounters. Ninety-seven variables input from the
PPNs or SOS MSEFs were significantly different at the P
.05 level,
whereas 38 variables were not. Insufficient data was recorded for a
determination of significance in 3 variables. For 121 variables, more data
were recorded using the SOS MSEFs than PPNs; for 84 variables, the amount of
data recorded exceeded twice that recorded using PPNs. For 10 variables, more
data were recorded in PPNs; however, these differences were not significant.
The authors conclude that the SOS MSEF is superior to PPNs for recording
patient-encounter data in the osteopathic care setting. Moreover, they argue
that the use of the validated SOS MSEF nationwide would ensure that
osteopathic physicians would be recording data in a similar manner for uniform
insurance claim coding, easy tracking of physicians-in-training and patient
outcomes, and data collection for future research.
This article has been cited by other articles:
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M. M. Patterson Documentation, Coding, and Reimbursement: An Outcomes-Based Northup Award Winner J Am Osteopath Assoc, January 1, 2006; 106(1): 7 - 8. [Full Text] [PDF] |
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