Outpatient Osteopathic SOAP Note Form: preliminary results in osteopathic outcomes-based research.

Abstract

One of the persistent challenges facing the osteopathic medical profession has been the lack of a reliable, easy-to-use, validated system for recording, collecting, and evaluating clinical findings in a format that is suitable for long-term data collection. As a result of the recent emphasis on outcomes-based research in the field of medicine, the creation and use of a standardized tool for the osteopathic profession has been pursued with increased urgency. In this study, the authors used participant-completed and previously validated Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Forms (SNFs) and Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note--Follow-up Forms to obtain answers to 17 outcomes-based questions that the profession must address to meet the new challenges and demands of outcomes-based research. A consortium of 10 osteopathic physicians and 196 osteopathic residents and undergraduate fellows submitted a total of 3908 patient SNFs for analysis. Answers to these 17 questions were computed using appropriate statistical determinants (eg, frequencies, correlations). Retrospective analysis indicated that, in addition to the outcomes addressed in this study, use of the SNF could be extended to the following functions: pre- and postdoctoral tracking, outcomes research into the efficacy of osteopathic intervention, medical science research, autonomic correlation with disease entities, etiology of musculoskeletal dysfunction, billing information, and internal comparison studies between osteopathic physicians. A long-term goal of the SNF project is to create an electronic national database for osteopathic outcomes-based research.