Standardized medical record: A new Outpatient Osteopathic SOAP Note Form: Validation of a standardized office form against physician's progress notes

摘要

The accuracy and efficiency of recording information on a one-page standardized Outpatient Osteopathic SOAP Note Form (SNF) was compared with that obtained using the physician's progress notes (PPN). Use of the SNF in lieu of the PPN would assure the physician that proper clinical data were recorded to ensure proof of need and care in any instances of refused reimbursement. Moreover, standardized SNFs could be used to document and analyze present treatment protocols, enabling medical advances. Ten osteopathic physicians, who were skilled in osteopathic manipulative treatment (OMT), enrolled 300 patients. Initial and follow-up examinations totaled 959 visits (statistical cases); 76 statistical variables were compared. Essentially all information recorded in the PPN was recorded on the SNF. A significant difference (P .05) was found between the PPN data set and the SNF data set in all but 17 of the 76 variables. Greater content of information almost always was found with the SNF data set. In addition, the SNF contained information not found in the PPN, most notably the severity and response to treatment of detected somatic dysfunctions. Participating physicians stated that the SNF takes about the same amount of time to fill in as the PPN. This makes the SNF a practical instrument for accurately and efficiently obtaining patient data in all physicians' offices. The validation study conducted demonstrated that the Outpatient Osteopathic SOAP Note Form easily and accurately reflected information recorded in the PPN and that data recorded may be used by physicians in their individual practices or for the conduct of osteopathic research.