Documentation, Coding, and Reimbursement: An Outcomes-Based Northup Award Winner
http://www.100md.com
《美国整骨期刊》
Nova Southeastern University College of Osteopathic Medicine in Davie, Fla. Dr Patterson is an associate editor of JAOA—The Journal of the American Osteopathic Association.
"If it isn't documented, it didn't happen."
A phrase often used by medical faculty when training future physicians and researchers.
In medical research, documentation is of paramount importance. Those who teach research methods often use the phrase "If it isn't documented, it didn't happen" to encourage budding researchers to write down everything that happens while they are conducting studies.
Physicians also know the importance of documenting every aspect of every patient encounter, from taking down patient histories to performing physical examinations. However, in many instances, the documentation of patient visits remains a tedious process of handwriting notes after the patient visit is complete—a potentially hit-or-miss, time-consuming exercise.
This year, the American Osteopathic Association's (AOA) editor in chief, the associate editors of JAOA—The Journal of the American Osteopathic Association (myself included), and the JAOA's editorial advisory board are pleased to congratulate Sandra L. Sleszynski, DO, Thomas Glonek, PhD, and William A. Kuchera, DO, for "changing the way osteopathic physicians practice [medicine], think, and conduct research" by presenting them with the George W. Northup, DO, Medical Writing Award for their October 2004 contribution to THE JOURNAL, "Outpatient Osteopathic Single Organ System Musculoskeletal Exam Form series: validation of the Outpatient Osteopathic SOS Musculoskeletal Exam Form, a new standardized medical record."1
In their award-winning article, these three authors provide a new means of documenting information that has important ramifications for both clinical practice and research within the osteopathic medical profession. This article is actually the third in a series of articles on the development of two form series for use by osteopathic physicians: the Outpatient Osteopathic SOS (Single Organ System) Musculoskeletal Exam Form Series (SOS-FS) and, its predecessor and companion, the Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form Series (SNFS). This third article, however, describes the validation of one form in the four-page SOS-FS, the Outpatient Osteopathic SOS Musculoskeletal Exam Form (SOS MSEF). The SNFS and the SOS-FS were developed by the American Academy of Osteopathy's Louisa Burns Osteopathic Research Committee under the guidance of Dr Sleszynski, who chaired that committee for several years.
Fourteen trained and certified osteopathic investigators entered patient data on the SOS MSEF, in addition to handwriting traditional physician progress notes (PPNs), for a total of 165 patients. Comparison of the PPNs with SOS MSEFs revealed that in almost every information area, the SOS MSEFs captured more patient data than did the PPNs. There were no data elements in which significantly less data were captured in the SOS MSEF than in traditional PPNs. In addition, once physicians were trained and certified in its use, the SOS MSEF actually took less time to complete than PPNs.
Finally, the use of the SOS MSEF also benefited one family practice office by streamlining the insurance claims-coding process for the osteopathic physician, resulting in increased annual revenue of over $18,000 during the study period.
The facts that these forms can potentially help osteopathic physicians gather more patient data more quickly and generate greater income for their medical practices are strong enough recommendations for their use. However, the potential applications of data gathered with the SOS-FS and SNFS are even more promising for the health and vitality of the profession as a whole.
It has not been a secret that the osteopathic medical profession has had some difficulty systematically gathering data on those aspects of its practice that are unique to osteopathic medicine, namely the prevalence and history of somatic dysfunction and patient response to osteopathic manipulative treatment. The widespread use of these forms holds the promise of filling this urgent need within the profession.
Because the forms are standardized and validated, they can be used to capture data on large numbers of patients with a wide variety of somatic dysfunctions, presenting complaints, and treatment regimens. Data gathered in this way over several years can provide osteopathic medical researchers with an invaluable resource for long-term, clinical investigations of somatic dysfunction with large population sizes. In conjunction with the electronic data-gathering capabilities currently being developed by the Louisa Burns Osteopathic Research Committee's e-SOAP project, outcomes-based data-gathering and datamining will become realities for the osteopathic medical profession in the coming years.
In fact, already in the past year, two sets of researchers4,5 have published original contributions in the JAOA that have relied on data gathered using the SNFS.
Either in combination or separately, the three articles by Sleszynski, Glonek, and Kuchera1-3 clearly meet the criteria for the George W. Northup, DO, Medical Writing Award. The potential of the SOS-FS and the SNFS for enhancing practice rigor (and income), and for contributing to the research knowledge of osteopathic medicine, is profound. It is entirely fitting that the 2005 George W. Northup, DO, Medical Writing Award should be given to the writers of the third article in this significant and welldone series.
Editor's note: Physicians may obtain copies of the Outpatient Osteopathic SOS (Single Organ System) Musculoskeletal Exam Form Series and/or the Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form Series from the American Academy of Osteopathy.
Address correspondence to: American Academy of Osteopathy, 3500 DePauw Blvd Ste 1080, Indianapolis, IN 46268-1174, or call (317) 879-1881.
References
2. Sleszynski SL, Glonek T, Kuchera WA. Standardized medical record: a new outpatient osteopathic SOAP note form: validation of a standardized office form against physician's progress notes. J Am Osteopath Assoc. 1999;99:516 -529.
5. Licciardone JC, Nelson KE, Glonek T, Sleszynski SL, Cruser DA. Osteopathic manipulative treatment of somatic dysfunction among patients in the family clinic setting: a retrospective analysis. J Am Osteopath Assoc. 2005;105:537 -544.(Michael M. Patterson, PhD)
"If it isn't documented, it didn't happen."
A phrase often used by medical faculty when training future physicians and researchers.
In medical research, documentation is of paramount importance. Those who teach research methods often use the phrase "If it isn't documented, it didn't happen" to encourage budding researchers to write down everything that happens while they are conducting studies.
Physicians also know the importance of documenting every aspect of every patient encounter, from taking down patient histories to performing physical examinations. However, in many instances, the documentation of patient visits remains a tedious process of handwriting notes after the patient visit is complete—a potentially hit-or-miss, time-consuming exercise.
This year, the American Osteopathic Association's (AOA) editor in chief, the associate editors of JAOA—The Journal of the American Osteopathic Association (myself included), and the JAOA's editorial advisory board are pleased to congratulate Sandra L. Sleszynski, DO, Thomas Glonek, PhD, and William A. Kuchera, DO, for "changing the way osteopathic physicians practice [medicine], think, and conduct research" by presenting them with the George W. Northup, DO, Medical Writing Award for their October 2004 contribution to THE JOURNAL, "Outpatient Osteopathic Single Organ System Musculoskeletal Exam Form series: validation of the Outpatient Osteopathic SOS Musculoskeletal Exam Form, a new standardized medical record."1
In their award-winning article, these three authors provide a new means of documenting information that has important ramifications for both clinical practice and research within the osteopathic medical profession. This article is actually the third in a series of articles on the development of two form series for use by osteopathic physicians: the Outpatient Osteopathic SOS (Single Organ System) Musculoskeletal Exam Form Series (SOS-FS) and, its predecessor and companion, the Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form Series (SNFS). This third article, however, describes the validation of one form in the four-page SOS-FS, the Outpatient Osteopathic SOS Musculoskeletal Exam Form (SOS MSEF). The SNFS and the SOS-FS were developed by the American Academy of Osteopathy's Louisa Burns Osteopathic Research Committee under the guidance of Dr Sleszynski, who chaired that committee for several years.
Fourteen trained and certified osteopathic investigators entered patient data on the SOS MSEF, in addition to handwriting traditional physician progress notes (PPNs), for a total of 165 patients. Comparison of the PPNs with SOS MSEFs revealed that in almost every information area, the SOS MSEFs captured more patient data than did the PPNs. There were no data elements in which significantly less data were captured in the SOS MSEF than in traditional PPNs. In addition, once physicians were trained and certified in its use, the SOS MSEF actually took less time to complete than PPNs.
Finally, the use of the SOS MSEF also benefited one family practice office by streamlining the insurance claims-coding process for the osteopathic physician, resulting in increased annual revenue of over $18,000 during the study period.
The facts that these forms can potentially help osteopathic physicians gather more patient data more quickly and generate greater income for their medical practices are strong enough recommendations for their use. However, the potential applications of data gathered with the SOS-FS and SNFS are even more promising for the health and vitality of the profession as a whole.
It has not been a secret that the osteopathic medical profession has had some difficulty systematically gathering data on those aspects of its practice that are unique to osteopathic medicine, namely the prevalence and history of somatic dysfunction and patient response to osteopathic manipulative treatment. The widespread use of these forms holds the promise of filling this urgent need within the profession.
Because the forms are standardized and validated, they can be used to capture data on large numbers of patients with a wide variety of somatic dysfunctions, presenting complaints, and treatment regimens. Data gathered in this way over several years can provide osteopathic medical researchers with an invaluable resource for long-term, clinical investigations of somatic dysfunction with large population sizes. In conjunction with the electronic data-gathering capabilities currently being developed by the Louisa Burns Osteopathic Research Committee's e-SOAP project, outcomes-based data-gathering and datamining will become realities for the osteopathic medical profession in the coming years.
In fact, already in the past year, two sets of researchers4,5 have published original contributions in the JAOA that have relied on data gathered using the SNFS.
Either in combination or separately, the three articles by Sleszynski, Glonek, and Kuchera1-3 clearly meet the criteria for the George W. Northup, DO, Medical Writing Award. The potential of the SOS-FS and the SNFS for enhancing practice rigor (and income), and for contributing to the research knowledge of osteopathic medicine, is profound. It is entirely fitting that the 2005 George W. Northup, DO, Medical Writing Award should be given to the writers of the third article in this significant and welldone series.
Editor's note: Physicians may obtain copies of the Outpatient Osteopathic SOS (Single Organ System) Musculoskeletal Exam Form Series and/or the Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form Series from the American Academy of Osteopathy.
Address correspondence to: American Academy of Osteopathy, 3500 DePauw Blvd Ste 1080, Indianapolis, IN 46268-1174, or call (317) 879-1881.
References
2. Sleszynski SL, Glonek T, Kuchera WA. Standardized medical record: a new outpatient osteopathic SOAP note form: validation of a standardized office form against physician's progress notes. J Am Osteopath Assoc. 1999;99:516 -529.
5. Licciardone JC, Nelson KE, Glonek T, Sleszynski SL, Cruser DA. Osteopathic manipulative treatment of somatic dysfunction among patients in the family clinic setting: a retrospective analysis. J Am Osteopath Assoc. 2005;105:537 -544.(Michael M. Patterson, PhD)