Outpatient Osteopathic Single Organ System Musculoskeletal Exam Form series: validation of the Outpatient Osteopathic SOS Musculoskeletal Exam Form, a new standardized medical record.

Abstract

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 MSEF-which 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 < or = .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.