Sleszynski Sandra L, Glonek Thomas, Kuchera William A
Crossroads Premiere Health Care, SC, 1010 35 Street, Kenosha, WI 53140, USA.
J Am Osteopath Assoc. 2004 Oct;104(10):423-38.
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.
作者验证了门诊整骨疗法SOS（单一器官系统）肌肉骨骼检查表格（SOS MSEF），这是一份1页的表格，包含在4页的门诊整骨疗法单一器官系统肌肉骨骼检查表格系列（SOS-FS）中。将病历中的手写医生病程记录（PPN，被视为临床记录的“金标准”）与同一患者就诊时填写在SOS MSEF上的信息进行比较。14名经过培训和认证的调查人员在标准化的SOS MSEF（该表格设计用于与先前验证的门诊整骨疗法SOAP（主观、客观、评估、计划）记录表格（SNF）配合使用）上记录的数据，与这些调查人员在PPN中记录的数据进行比较。作者比较了医生在这两种格式下记录165例患者就诊的肌肉骨骼信息的准确性和效率。使用描述性统计和t检验来比较患者就诊后记录的数据。从PPN或SOS MSEF输入的97个变量在P≤0.05水平上有显著差异，而38个变量没有。有3个变量记录的数据不足，无法确定其显著性。对于121个变量，使用SOS MSEF记录的数据比PPN多；对于84个变量，记录的数据量超过使用PPN记录的数据量的两倍。对于10个变量，PPN中记录的数据更多；然而，这些差异并不显著。作者得出结论，在整骨疗法护理环境中记录患者就诊数据时，SOS MSEF优于PPN。此外，他们认为在全国范围内使用经过验证的SOS MSEF将确保整骨疗法医生以类似的方式记录数据，以实现统一的保险理赔编码、便于跟踪实习医生和患者结果以及为未来研究收集数据。
