Outpatient Osteopathic SOAP Note Form: Preliminary Results in Osteopathic Outcomes-Based Research

ORIGINAL CONTRIBUTION

Sandra L. Sleszynski, DO Thomas Glonek, PhD

One of the persistent challenges facing the osteopathic To retain its identity as a unified profession and to ensure medical profession has been the lack of a reliable, easy-to- appropriate reimbursement from third-party payers (eg, med- use, validated system for recording, collecting, and eval- ical insurers, Medicare, Medicaid), the osteopathic medical uating clinical findings in a format that is suitable for profession must provide complete documentation and evi- long-term data collection. As a result of the recent emphasis dence on the efficacy of its unique treatment methods. In addi- on outcomes-based research in the field of medicine, the tion, the profession must document the nationwide incidence creation and use of a standardized tool for the osteopathic of the particular disturbances osteopathic medicine claims to profession has been pursued with increased urgency. In treat best—namely, dysfunctions of the musculoskeletal system. this study, the authors used participant-completed and These two goals often pose a particular dilemma for the osteo- previously validated Outpatient Osteopathic SOAP (Sub- pathic medical profession, however, because a good portion of jective, Objective, Assessment, Plan) Note Forms (SNFs) the whole-person treatment offered by osteopathic physicians and Outpatient Osteopathic SOAP (Subjective, Objective, is difficult to document and quantify using the standard patient Assessment, Plan) Note – Follow-up Forms to obtain record format and physicians’ progress notes (PPNs). In addi- answers to 17 outcomes-based questions that the profession tion, although several validated tools have been available in the must address to meet the new challenges and demands of past, the profession does not have a widespread ability to doc- outcomes-based research. A consortium of 10 osteopathic ument osteopathic medicine’s most characteristic component, physicians and 196 osteopathic residents and undergrad- “the role of palpatory diagnosis and manipulative treatment uate fellows submitted a total of 3908 patient SNFs for in osteopathic teaching and practice”—an ability that is critical analysis. Answers to these 17 questions were computed to the profession’s long-term goals.1 using appropriate statistical determinants (eg, frequencies, correlations). Retrospective analysis indicated that, Background in addition to the outcomes addressed in this study, use of Measuring Clinical Outcomes: the SNF could be extended to the following functions: Evidence-Based Medicine pre- and postdoctoral tracking, outcomes research into the “Clinical outcomes” has become an important buzzword in the efficacy of osteopathic intervention, medical science lexicon of managed care. Measurements of clinical outcomes research, autonomic correlation with disease entities, eti- are used to predict the course of an illness and to analyze the ology of musculoskeletal dysfunction, billing informa- efficacy of available treatment modalities. tion, and internal comparison studies between osteopathic Outcomes data can be divided into three groups: input physicians. A long-term goal of the SNF project is to create (subject stratification by diagnosis), intervention, and out- an electronic national database for osteopathic outcomes- comes.2 Measuring clinical outcomes has been facilitated by the based research. addition of symptom data (chief complaint), as well as func- tional assessments.3 Analysis of clinical outcomes and the From the Osteopathic Manipulative Medicine Department at Midwestern incorporation of those results into the clinical setting leads to University’s Chicago College of Osteopathic Medicine in Downers Grove, Ill. Both authors are members of the Louisa Burns Osteopathic Research Com- the practice of what is called evidence-based medicine. mittee, of which Dr Glonek is the current chairman. Over the past several years, there has been increasing This study was funded by the Osteopathic Heritage Foundation, as rec- emphasis on outcomes measures, in particular on how various ommended by the Bureau of Research of the American Osteopathic Associ- ation and was completed in collaboration with the work of the Louisa Burns treatment modalities affect patients’ health status. This type of Osteopathic Research Committee of the American Academy of Osteopathy research does not look at mechanisms or causes of change in (http://academyofosteopathy.org/research_lborc.cfm). patients’ health status; its only concern is the end result of the Address correspondence to Sandra L. Sleszynski, DO, Crossroads Premiere Health Care, SC, 3200 Sheridan Rd, Ste 104, Kenosha, WI 53140-1921. clinical procedure or treatment under investigation. E-mail: [email protected]. Outcomes can include anything from physical data to

Sleszynski and Glonek • Original Contribution JAOA • Vol 105 • No 4 • April 2005 • 181 ORIGINAL CONTRIBUTION patient quality of life and activities of daily living. Healthcare hospitals as a result of evidence that osteopathic structural costs can also be examined, as can a combination of factors. evaluations were either not being performed on inpatients or As managed-care organizations and government agencies that findings from those examinations were inaccurately increasingly rely on clinical outcomes measures to develop recorded in patient medical records.15 clinical practice guidelines, physicians will be asked to conform Although there have been attempts to present a stan- to these guidelines in their practices.4,5 dardized format for such examinations,16 and standardiza- It has been suggested that a central resource, such as a pro- tion for research protocols have been discussed in various fessional organization or association, spearhead the develop- forums,17–25 most of these efforts have been focused on pro- ment of such clinical practice guidelines with the active par- viding complete guidelines for documenting osteopathic diag- ticipation of member-physicians.6 By participating in this and nosis and somatic dysfunctions—a process that would be too similar processes, clinicians become de facto researchers and cumbersome for use with large groups of geographically also, of necessity, develop lifelong learning skills. In addition, diverse osteopathic physicians in outcomes-based research such participation ensures more physician control of what projects. seems to be a shared destiny. In March 1989, the Louisa Burns Osteopathic Research The creation of outcomes-based clinical practice guidelines Committee (LBORC), the research branch of the American for osteopathic medicine would serve to standardize osteo- Academy of Osteopathy (AAO), began looking into a solution pathic medical care on a national basis, and would also stream- to these and other problems—as well as looking forward to line the process of professional education assessment. Curricula larger possibilities for osteopathic medical research once these in graduate medical education programs are already changing initial challenges were addressed.26–32 to more accurately reflect the current practice of medicine, which The original SOAP (Subjective, Objective, Assessment, takes an integrated, problem-oriented approach. Plan) Notes Form (SNF)—which was designed, published, In the present medical environment, it is essential that and distributed in 1998 (Figure 1)—covers the range of exami- the osteopathic medical profession be able to conduct clinical nation and treatment activities performed by osteopathic physi- outcomes-based studies. Methods of clinical data collection cians during a patient encounter, enabling physicians to record in practice-based settings must be developed and validated to data on a standard osteopathic musculoskeletal examination, enable osteopathic medical investigators to validate available enumerate any musculoskeletal dysfunctions found, docu- prevention, diagnostic, and treatment modalities. ment any OM techniques used, and report patient response to treatment. The 1998 SNF was a first step in providing stan- Developing the Evidence Base dardized documentation for osteopathic outpatient practice for Osteopathic Medicine in the United States. There have been many reports on the efficacy of osteopathic A recent outgrowth of the Committee’s work with the evaluation methods and osteopathic manipulative treatment SNF has been the creation of a coordinating form that is (OMT) in the management of a host of diseases and disor- problem oriented (ie, based on the patient’s chief complaint). ders of structure and function.7–9 However, corresponding This newer four-page form is known as the Outpatient Osteo- basic science data in support of these findings—and that pathic Single Organ System Musculoskeletal Exam Form Series involve large numbers of human subjects—are relatively (SOS-FS). Thanks to a grant from the American Osteopathic absent, primarily, we suggest, as a result of a lack of appropriate Association (AOA), the Outpatient Osteopathic SOS (Single investigative technologies.10,11 Organ System) Musculoskeletal Exam Form (SOS MSEF), a The solution to these deficiencies—and the key to the one-page form contained within the SOS-FS, was recently val- survival of the distinct clinical practice of osteopathic idated against PPNs.26,27 medicine—lies in cultivating solid osteopathic clinical out- In recent years, sufficient data have been collected since comes data on a national scale. This goal, however, assumes the creation of the first edition of the SNF that members of standardization of osteopathic nomenclature and reporting the Committee (S.L.S., T.G.) were able to test the form for its methods involving trained investigators. intended use, outcomes research, in the present study. Present The Louisa Burns Osteopathic Research Committee As a result of the recent emphasis on outcomes-based research and the SOAP Notes Form Project in the field of medicine, the creation and use of a standard- Past ized tool for the osteopathic profession has been pursued by the The problem-oriented medical record (known as PROMIS) LBORC with a renewed sense of urgency.33,34 The need is acute was developed by Lawrence L. Weed, MD, in the 1950s and for a standardized documentation format that allows osteo- late 1960s,12–14 and calls within the osteopathic medical pro- pathic physicians to consistently report the incidence, symptom fession for a common record-keeping system for osteopathic severity, treatment methods used, and related clinical out- physicians based on the use of OMT did not follow far behind.10 comes for their patients with musculoskeletal dysfunction. The Studies in subsequent years recommended the development SNFs and the SOS-FS are valid and reliable tools that could of similar standardized record-keeping systems in osteopathic readily fill this gap with widespread adoption within the osteo-

182 • JAOA • Vol 105 • No 4 • April 2005 Sleszynski and Glonek • Original Contribution ORIGINAL CONTRIBUTION

Figure 1. Sample Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form. (Reprinted with permission of the American Academy of Osteopathy. This form was originally published in JAOA—The Journal of the American Osteopathic Association in October 1999.26) This version of the SNF is no longer in use in clinical settings, however, having been updated after the present study was conducted. For the current version of this form, the second edition of the Outpatient Osteopathic SOAP Note Form Series (SNF-2E), please see the appendix, on pages 202 through 205 of this issue.

Sleszynski and Glonek • Original Contribution JAOA • Vol 105 • No 4 • April 2005 • 183 ORIGINAL CONTRIBUTION

Figure 2 (1 of 2). Sample Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note – Follow-up Form. This form consists of two pages. (Reprinted with permission of the American Academy of Osteopathy.) Copies of the Outpatient Osteopathic SOAP Note Form can be obtained from the American Academy of Osteopathy, 3500 DePauw Blvd, Ste 1080, Indianapolis, IN 46268-1136; telephone: (317) 879- 1881. This form is also available online at http://www.academyofosteopathy.org/research_soap.cfm in a PDF (portable document format) file.

184 • JAOA • Vol 105 • No 4 • April 2005 Sleszynski and Glonek • Original Contribution ORIGINAL CONTRIBUTION

Figure 2 (2 of 2). Sample Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note – Follow-up Form. This form consists of two pages. (Reprinted with permission of the American Academy of Osteopathy.) Copies of the Outpatient Osteopathic SOAP Note Form can be obtained from the American Academy of Osteopathy, 3500 DePauw Blvd, Ste 1080, Indianapolis, IN 46268-1136; telephone: (317) 879- 1881. This form is also available online at http://www.academyofosteopathy.org/research_soap.cfm in a PDF (portable document format) file.

Sleszynski and Glonek • Original Contribution JAOA • Vol 105 • No 4 • April 2005 • 185 ORIGINAL CONTRIBUTION

pathic medical profession.26,29 In fact, preliminary studies have successfully used the 1998 SNF to collect and report incidence Outcomes-Based Research Questions of disease entities within a family practice setting.28 It is clear that if the osteopathic medical profession is to sur- vive and remain financially viable to its practitioners in an 1. What is the incidence in women and men? increasingly competitive climate of healthcare provision, it 2. What is the incidence of severity (scale = 0 must provide accurate statistics on the nationwide incidence [lowest], 1, 2, 3 [highest]) of somatic dysfunction of diseases and disorders it treats. The profession must also pro- in each region of the musculoskeletal table? vide new research based on these patient outcomes in support of osteopathic principles and practice (OPP). 3. What is the incidence of somatic dysfunction A standardized and widely used medical record is an in each designated body region? essential requirement for these projects. Such standardization could eventually provide the basis for national database of 4. What is the incidence of osteopathic osteopathic outcomes information that would be useful in manipulative treatment (OMT) by body region? documenting the efficacy of OMT for our patients and other 5. What is the incidence of specific osteopathic researchers as well as for medical, legal, insurance, and other manipulative (OM) techniques used? third-party groups. The present study is the continuation of the long-term 6. What is the incidence of responses (resolved, SNF project,26–32 and was designed to show that the first edi- improved, unchanged, and worse) by body tion of the Outpatient Osteopathic SNF (Figure 1) and the Out- region following OMT? patient Osteopathic SOAP Note – Follow-up Form (Figure 2) allow researchers to efficiently and effectively gather answers 7. What is the incidence of physician’s evaluation to basic outcomes-oriented questions. The 17 questions used before OMT for first visit: resolved, improved, (Figure 3) were designed by study investigators to measure inci- unchanged, and worse? dence of somatic dysfunction, calculate averages, establish 8. What is the incidence of diseases by ICD-9 code? correlations, and make simple comparisons. Researchers were able to answer all 17 questions efficiently 9. What is the incidence of OMT performed and effectively using the data provided on the 1998 SNF. Inci- and recorded for 1 to 2, 3 to 4, 5 to 6, dence questions addressed severity of somatic dysfunction, 7 to 8, and 9 to 10 musculoskeletal body regions? the number of regions treated with OMT, OM techniques used, and subject responses to treatment. Averages questions (eg, 10. What is the most frequently recommended subject age, duration of initial visit, time elapsed to follow-up) follow-up time? were also answered. Correlation questions (eg, disease entity 11. What is the average age of patients treated? and specific OM techniques used, severity of somatic dysfunction and subject response to OMT) were answered, as 12. What is the average visit duration? were questions on differences among diagnoses made by osteopathic physicians (eg, the top four International Classification of 13. What was the average number of regions Diseases, 9th Revision (ICD-9-CM)35 diagnosis codes). evaluated and/or treated with OMT? In addition to answering the aforementioned outcomes 14. Was there a correlation between disease questions, the SNF and its follow-up form could also be used entity and specific OM techniques used? to address the following functions: pre- and postdoctoral and tracking, additional outcomes research into the efficacy of 15. Is there a correlation between severity of osteopathic intervention, medical science research, autonomic somatic dysfunction and the response to correlation with disease entities, etiology of musculoskeletal treatment? dysfunction, billing information, and facilitation of internal comparisons among osteopathic physicians. 16. Is there a correlation between disease entity Future and the top 4 most severe body regions for Beyond the immediate concerns, however, members of the pro- somatic dysfunction? fession should consider the long-term value of a widely acces- 17. What are the most frequently diagnosed sible database of clinical information that facilitates and accel- and treated regions among providers? erates medical outcomes research within osteopathic medicine. Consider, for example, the Danish “Better Health for Mother and Child” cohort study. The goal of this long-term Figure 3. Seventeen Outcome-Based Questions national outcomes project was the creation of a database that Facing the Osteopathic Profession. generations of investigators can use for studies on the effects of

186 • JAOA • Vol 105 • No 4 • April 2005 Sleszynski and Glonek • Original Contribution ORIGINAL CONTRIBUTION medical treatments.36 Medical researchers in the United States, from each of the three agencies with oversight at the colleges however, have historically preferred to design studies that of osteopathic medicine and hospitals where physician-par- answer specific questions and allow for long-term follow up. ticipants were employed: Colorado Springs Osteopathic Foun- One great strength of the SNF project is that it incorporates dation Research Review Administration (Colorado Springs, outcomes and clinical-trials methodologies. The goal of the Colo), Midwestern University Institutional Review Board SNF project is to create an osteopathic medical database for data (Downers Grove, Ill), and the University of North Texas Health mining following the Danish model while also conforming Science Center at Fort Worth Texas College of Osteopathic to the US model of answering specific clinical questions using Medicine (UNTHSC) Institutional Review Board for the Pro- the data available. tection of Human Subjects. As noted, a persistent problem faced by the osteopathic All 10 osteopathic physicians who participated in this medical profession has been a relative lack of reliable, easy-to- study were trained and certified in the use of the SOS-FS, which use systems of recording and collecting clinical findings in a contained the trial SOS MSEF.26 These 10 osteopathic physicians format that is suitable for subsequent data collection. This lack were asked to submit cases for the present study. Four physi- has been, in part, responsible for the lack of a referable database cian-participants practice musculoskeletal medicine mainly; from osteopathic physicians on the general parameters of another four had practices that consisted of at least 40% mus- osteopathic practice and the prevalence, frequency, and severity culoskeletal medicine; the remaining physician-participants of somatic dysfunction in various patient populations—as practice some other form of medicine. Two undergraduate well as the clinical effects of OMT. research fellows at one of the colleges of osteopathic medicine One goal of the LBORC’s SNF project is the creation of an were also chosen to participate in the present study. All physi- electronic record of the outpatient osteopathic SNF for use by cian-participants were board certified in neuromusculoskeletal all osteopathic physicians and surgeons in the United States. medicine to ensure a standard of competence in examination The electronic version of the SNF (SNF EV) will include all stan- techniques and diagnosis. Further, physician-participants were dard demographic and medical information, as well as infor- chosen from various backgrounds: teaching institutions, private mation and data specific to the practice of osteopathic medicine. practice, and group practice. Prior to the start of this study, all The LBORC intends that SNF EV data will be transmitted via 10 physician-participants were trained by the primary investi- the Internet to a secure centralized location and that the data gator (S.L.S.) and LBORC members in data collection using will be made available for use online by national and inter- the SOS MSEF. The training sessions and certifications enhanced national physicians, researchers, and clinical investigators. interexaminer reliability in this multisite study. One of the principal advantages of using the multisite In addition, 196 osteopathic residents and undergraduate SNF EV as proposed by the LBORC is that participants will fellows were selected to serve as participants in the present have the ability to record large quantities of patient data within study.40 Osteopathic medical students were included as par- a central repository over a relatively short period of time. With ticipants in the present to obtain their feedback on the forms, HIPAA (Health Insurance Portability and Accountability Act to involve them in the future of the profession, to encourage of 1996)-compliant oversight, data may then be analyzed in clin- their familiarity with the forms (also enabling them to teach ical research studies, vastly increasing efficiency over con- their peers about the forms’ use), and to provide them with ventional (analog) methods. Participating clinicians would experience in participating in a multisite research project. then be able to link the proposed SNF EV to decision support All participants were either trained and certified during systems and have the option of modifying their practice pat- courses at AOA or AAO conventions or were provided with terns in response to a quickly changing environment.37–39 private tutorials on the use of the SNFs and their follow-up forms. Participants who were tested and certified obtained a Methods passing score in the transcription of cases onto the SOS MSEF, This retrospective study involves the recording of informa- as described elsewhere.29 All 10 participating osteopathic tion from PPNs and is limited to the observation of note- physicians had been using the outpatient osteopathic SNF keeping in outpatient medical offices. No patient names or routinely in their practice for at least six months before par- identifying information were used. No changes in patient care ticipation in the present study. or treatment procedures were involved. This study, therefore, Among physician-participants, four were in private prac- is exempt from the requirement for full institutional review tice in various regions of the United States: Wisconsin, Illi- board review and informed consent agreements from study nois, Colorado, or New York. Among the records from the subjects taking part in original medical research as noted by 196 osteopathic residents and undergraduate fellows, seven National Institutes of Health and Office for Human Research participating residents were based at these private practice Protections guidelines. sites; SNFs for this group were completed under the supervi- The study began after researchers received approval from sion of physician-participants. the Biotechnical Institute’s Human Subjects Committee at the The research site at UNTHSC provided the records of six University of Wisconsin at Parkside in Kenosha (ie, at the attending physicians and 189 osteopathic residents and under- data-collection site). Approval was also sought and obtained graduate fellows. At the Wisconsin site, there was one attending

Sleszynski and Glonek • Original Contribution JAOA • Vol 105 • No 4 • April 2005 • 187 ORIGINAL CONTRIBUTION

Table 1 SOAP Note Form* Outcomes Research: Incidence of Somatic Dysfunction by Severity and Body Region (N=3908)

Frequency by Severity, No. (%)

Region Evaluated 0 (Lowest) 1 2 3 (Highest) Head and Face 38 (1.0) 376 (9.6) 828 (21.2) 864 (22.1) Cervical (Neck) 44 (1.1) 456 (11.7) 940 (24.1) 947 (24.2) Thoracic ▫ T1 to T4 36 (0.9) 473 (12.1) 921 (23.6) 801 (20.5) ▫ T5 to T9 37 (0.9) 457 (11.7) 734 (18.8) 660 (16.9) ▫ T10 to T12 86 (2.2) 807 (20.6) 609 (15.6) 233 (6.0) Ribs 33 (0.8) 463 (11.8) 828 (21.2) 443 (11.3) Lumbar 60 (1.5) 508 (13.0) 766 (19.6) 908 (23.2) Sacrum 101 (2.6) 796 (20.4) 724 (18.5) 613 (15.7) Pelvis 72 (1.8) 873 (22.3) 761 (19.5) 376 (9.6) Abdomen 66 (1.7) 215 (5.5) 582 (14.9) 351 (9.0) Extremities, Upper ▫ Right 92 (2.4) 276 (7.1) 356 (9.1) 243 (6.2) ▫ Left 107 (2.7) 291 (7.4) 301 (7.7) 236 (6.0) Extremities, Lower ▫ Right 82 (2.1) 289 (7.4) 419 (10.7) 290 (7.4) ▫ Left 93 (2.4) 275 (7.0) 366 (9.4) 268 (6.9)

* SOAP Note Form indicates Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form.

physician. At a hospital site in Illinois, there was one attending primary investigator (S.L.S.). Participants were asked to ensure physician, one osteopathic manipulative medicine intern, and that an ICD-9-CM numeric code was provided for each record three osteopathic medical students. submitted; records that contained written diagnoses instead In November 2002, study investigators (S.L.S. and T.G.) had to be coded by participants before submission. Each of the began a retrospective chart review of SNFs completed from Jan- six study sites maintained a log of each SNF with the fol- uary 2001 through June 2002. lowing information: Records submitted by participating osteopathic physi- ▫ patient’s name, cians, residents, and undergraduate fellows for review and ▫ patient’s corresponding unique identifier analysis by study investigators had to meet one of the fol- (assigned by participant), lowing criteria: (1) Participants who were technologically able ▫ participant’s AOA member number to track patient visits by date through paper or electronic (also known as “Record ID”), records were asked to make photocopies of SNFs for each ▫ resident letter, if appropriate, subject seen from January 1, 2001, to May 31, 2002, for sub- ▫ case number, mission into the study; or (2) Participants who were not tech- ▫ patient’s letter on PPNs, as appropriate, for multiple nologically able to track patient visits by date were asked sequential dates of service (eg, a patient receiving care on instead to make photocopies of and submit every third SNF January 3, 2002, and February 14, 2002, would have the (with accompanying PPNs) in their chart file. To ensure ade- letters A and B assigned to those PPNs, respectively), quate sampling of patient medical records, a maximum limit ▫ date of office visit documented, and of 14 PPNs was set for submission of SNFs on any one subject. ▫ an indicator if the documented visit To maintain patient confidentiality, participants were was an initial patient visit. instructed to remove protected patient information and to All participating osteopathic physicians, residents, and under- place a randomly assigned 5-digit subject-specific identifier graduate fellows were also asked to maintain a secure per- on submitted materials for each subject. Number ranges for par- sonal log of their copied patient records with their unique ticipants to assign to their patient records were provided by the identifiers to protect patient confidentiality and act as a point 188 • JAOA • Vol 105 • No 4 • April 2005 Sleszynski and Glonek • Original Contribution ORIGINAL CONTRIBUTION

Table 2 Table 3 SOAP Note Form* Outcomes Research: SOAP Note Form* Outcomes Research: Incidence of Somatic Dysfunction by Body Region (N=3908) OMT for Patients with Somatic Dysfunction by Body Region (N=3908) Region Evaluated No. (%) Head and Face 2603 (66.6) Region Treated No. (%) Rank Cervical (Neck) 2838 (72.6) Head and Face 2115 (54.1) 5 Thoracic Cervical (Neck) 2370 (60.6) 1 ▫ T1 to T4 2772 (70.9) Thoracic ▫ T5 to T9 2445 (62.6) ▫ T1 to T4 2206 (56.4) 2 ▫ T10 to T12 2106 (53.9) ▫ T5 to T9 1820 (46.6) 7 Ribs 2345 (60.0) ▫ T10 to T12 1640 (42.0) 9 Lumbar 2596 (66.4) Ribs 1768 (45.2) 8 Sacrum 2597 (66.5) Lumbar 2182 (55.8) 3 Pelvis 2536 (64.9) Sacrum 2174 (55.6) 4 Abdomen 1633 (41.8) Pelvis 2010 (51.4) 6 Extremities, Upper Abdomen 1142 (29.2) 10 ▫ Right 1218 (31.2) Extremities, Upper ▫ Left 1046 (26.8) ▫ Right 847 (21.7) 13 Extremities, Lower ▫ Left 782 (20.0) 14 ▫ Right 1640 (42.0) Extremities, Lower ▫ Left 1340 (34.3) ▫ Right 973 (24.9) 11 ▫ Left 898 (23.0) 12 * SOAP Note Form indicates Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form. * SOAP Note Form indicates Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form; OMT, osteopathic manipulative treatment. of reference for further inquiry should questions arise from investigators later. Participants were the only ones who had access to these logs; project personnel, including the investi- same physician) was greater than 99.8% and involved the gators, and participants’ staff members did not have access to reentry of five randomly assigned cases. Interdata reliability (ie, these personal logs. among physician-participants) was greater than 91%. In this All participants were asked to mail copied SNFs to the cen- study, 20 cases were selected for testing, and data-entry errors tral data-collection site at Crossroads Premiere Health Care, SC, were compared among the seven data-entry technicians. in Kenosha, Wisc, for statistical outcomes analysis on the use Once data entry was complete, the frequencies statistic was of this standardized clinical recording instrument. used to search for frame shifts in data entry (ie, large blocks of At the central data-collection site, records were reviewed data from a set of cases that had shifted as a result of deletion consistent with HIPAA directives regarding patient and physi- or duplication of one or more variables). Frame shifts were cor- cian confidentiality and assigned unique identifiers for physi- rected. Other errors, such as single cell errors or omissions, were cians and subjects were verified. Data processors at the study not corrected and were incorporated into the statistical anal- site color-coded files by study participant to assist in data ysis. Single cell errors or omissions represented valid physician organization. Color-coded files contained any SNFs submitted or data-entry errors. by that participant. Subsequent to data entry, the following four general types Seven staff members at the data-collection site were of questions were addressed: assigned to assist in data collection for the present study and Incidence—Subjects’ sex, severity of somatic dysfunction were instructed in proper data-entry methods by the principal (scale = 0 [lowest], 1, 2, 3 [highest]) for each body region, investigator (S.L.S.).27,30 A Microsoft Access (version 98, somatic dysfunction in each body region, number of regions Microsoft Corporation, Redmond, Wash) database that had treated with OMT, specific OM technique used, subject been previously created and approved to answer the outcomes response to OMT, physician’s evaluation before OMT, diag- questions posed for this study was used by these staff members. nosis by ICD-9-CM code, OMT performed by number of body To facilitate staff members’ data-entry tasks, the principal inves- regions, and physician-recommended follow-up time.30 tigator (S.L.S.) transcribed dictated PPNs onto SNFs. Averages—Subjects’ age, duration of office visit, and body Intradata reliability (ie, multiple records created by the regions evaluated and/or treated. Sleszynski and Glonek • Original Contribution JAOA • Vol 105 • No 4 • April 2005 • 189 ORIGINAL CONTRIBUTION

Table 4 SOAP Note Form* Outcomes Research: OMT of Somatic Dysfunction, Techniques Used in All Body Regions (N = 54,712†)

Osteopathic Manipulative Technique No. (%) ‡ Rank§ Articulatory 9831 (18.0) 2 Balanced ligamentous tension 3846 (7.0) 6 Cranial osteopathy 2287 (4.2) 8 Counterstrain 1328 (2.4) 9 Direct 8432 (15.4) 3 Facilitated positional release 560 (1.0) 13 High velocity – low amplitude 2618 (4.8) 7 Indirect 1059 (1.9) 10 Integrated neuromusculoskeletal release 156 (0.3) 14 Ligamentous articular strain 1042 (1.9) 11 Muscle energy 6810 (12.5) 4 Myofascial release 6511 (11.9) 5 Soft tissue 9869 (18.0) 1 Visceral 569 (1.0) 12

* SOAP Note Form indicates Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form; OMT, osteopathic manipulative treatment. † Population total was determined by multiplying 3908 subjects by the 14 body regions treated. For most subjects, multiple osteopathic manipulative (OM) techniques were used in the treatment of somatic dysfunction in multiple body regions. ‡ Percentages reported were rounded for each group by OM technique. Therefore, the sum of these percentages may not equal 100%. § Although two sets of data for OM techniques (ie, Articulatory and Soft tissue; Indirect and Ligamentous articular strain) indicated that they had the same percentage of use by participating osteopathic physicians, residents, and undergraduate fellows in treating subjects’ somatic dysfunctions, results for these two sets were ranked separately (ie, not both ranked 1 and 9, respectively) because of the available frequency data.

Correlations—Diagnosis and specific OM techniques used; Item 2: What is the incidence of severity (scale = 0 [lowest], 1, 2, 3 severity of somatic dysfunction and response to treatment; [highest]) of somatic dysfunction in each region of the muscu- and disease entity diagnosed and the top four most severe loskeletal table? forms of somatic dysfunction by body region.30 The most severe somatic dysfunctions occurred with the Differences—One overall comparison among osteopathic greatest frequency in the cervical region (24.2%), followed by physicians in subject diagnosis and treatment. the lumbar (23.2%), head (22.1%), and thoracic T1 to T4 (20.5%) Using SPSS statistical software (version 10.1, SPSS Inc, (Table 1). Chicago, Ill), appropriate statistical determinants were entered Within the thoracic region, T10 to T12 had the lowest and analyzed, such as frequencies, correlations, and outcomes reported frequency (6%) for the highest severity rating. computations involving multiple variables. For T1 to T4, T5 to T9, and ribs, fewer than 1% of responses were reported as “No somatic dysfunction found.” In other Results words, if somatic dysfunction is found in any these body Data from 3908 SNFs were entered by staff members at the regions, the physician may anticipate finding a nonzero level data-collection site. With 3908 cases, there were 259 variables, and of associated severity. 1,012,172 cells of information were computed. Following is a Item 3: What is the incidence of somatic dysfunction in each desig- summary of results by question type and item number (Figure 3): nated body region? Incidence Questions In this study population, the greatest incidence of somatic Item 1: What is the incidence in women and men? dysfunction was found in the cervical region (72.6%), with Data were reported for 2078 (72.4%) women and 792 (27.6%) the occurrence in thoracic T1 to T4 (70.9%) being nearly as Table 2 men. Data on the sex of subjects were missing in 1038 (26.6%) great ( ). cases. The lowest incidence of somatic dysfunction was found in the left upper extremity (26.8%). 190 • JAOA • Vol 105 • No 4 • April 2005 Sleszynski and Glonek • Original Contribution ORIGINAL CONTRIBUTION

Table 5 SOAP Note Form* Outcomes Research: Incidence of Somatic Dysfunction Resolved with OMT by Body Region (N=3908)

Within-Region Group Region Treated No. (%) Rank† Treated, No. Resolved,%

Head and Face 756 (19.3) 7 1933 39.2 Cervical (Neck) 730 (18.7) 8 2176 33.6 Thoracic ▫ T1 to T4 832 (21.3) 5 2016 41.3 ▫ T5 to T9 880 (22.5) 4 1687 52.2 ▫ T10 to T12 949 (24.3) 3 1547 61.3 Ribs 826 (21.1) 6 1589 52.0 Lumbar 970 (24.8) 2 2015 48.1 Sacrum 948 (24.3) 3 1995 47.5 Pelvis 1023 (26.2) 1 1871 54.7 Abdomen 314 (8.0) 9 1052 29.9 Extremities, Upper ▫ Right 260 (6.7) 11 799 32.5 ▫ Left 306 (7.8) 10 753 40.6 Extremities, Lower ▫ Right 231 (5.9) 13 869 26.6 ▫ Left 242 (6.2) 12 789 30.7 Total 9267‡ 21,091§ 42.2//

* SOAP Note Form indicates Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form; OMT, osteopathic manipulative treatment. † Data for two regions (ie, T10 to T12 and Sacrum) indicated that they have the same frequency and percentage of somatic dysfunction that resolved with OMT. Therefore, both regions are ranked third. ‡ When the total number of cases resolved with OMT (9267) is divided by the number of regions treated (14), results indicate that there was an average of 661.9 cases resolved per region. In other words, for each patient, 16.9% of somatic dysfunctions in each region were resolved after treatment. § The total treated (21,091) is larger than the total number of cases (3908), indicating that an average of 5.3 regions were treated with OMT in each patient visit. // The percentage of somatic dysfunction resolved, as reported, is an average value.

Overall, more somatic dysfunction was found in the spinal and myofascial release (11.9%) techniques. areas than in the extremities. Because the database used for the present study contains Item 4: What is the incidence of osteopathic manipulative treatment specific identifiers for participating osteopathic physicians, (OMT) by body region? residents, and undergraduate fellows, the data presented in Participants most commonly used OMT to treat subjects with Table 4 could theoretically have been subdivided by individual somatic dysfunction when that dysfunction was located in physicians, as well as by groups of physicians. Although the cervical region (60.6%) (Table 3). The next most frequently detailed physician-specific information was beyond the scope OMT-treated body region was thoracic T1 to T4 (56.4%), fol- of the present study, one can readily appreciate the potential lowed by the lumbar (55.8%) and sacral (55.6%) regions. The uses of such detailed results for future studies. head (54.1%) and pelvis (51.4%) ranked fifth and sixth, respec- Item 6: What is the incidence of responses (resolved, improved, tively, in frequency for OMT. unchanged, and worse) by body region following OMT? Item 5: What is the incidence of specific osteopathic manipulative In this study population, when somatic dysfunctions were (OM) techniques used? treated, most conditions were either resolved (Table 5) or Articulatory and soft tissue techniques (18% each) were the improved (Table 6). Few conditions were reported as most commonly used OM techniques (Table 4). These OM tech- unchanged (Table 7). There was only one instance in which a niques were followed by direct (15.4%), muscle energy (12.5%), subject’s condition actually worsened with OMT. Sleszynski and Glonek • Original Contribution JAOA • Vol 105 • No 4 • April 2005 • 191 ORIGINAL CONTRIBUTION

Table 6 SOAP Note Form* Outcomes Research: Incidence of Somatic Dysfunction Improved with OMT by Body Region (N=3908)

Within-Region Group

Region Treated No. (%) Rank† Treated, No. Improved, %

Head and Face 1169 (29.9) 2 1933 60.6 Cervical (Neck) 1434 (36.7) 1 2176 65.9 Thoracic ▫ T1 to T4 1170 (29.9) 2 2016 58.0 ▫ T5 to T9 793 (20.3) 6 1687 47.0 ▫ T10 to T12 587 (15.0) 10 1547 38.0 Ribs 748 (19.1) 7 1589 47.1 Lumbar 1027 (26.3) 4 2015 51.0 Sacrum 1040 (26.6) 3 1995 52.1 Pelvis 841 (21.5) 5 1871 45.0 Abdomen 735 (18.8) 8 1052 69.9 Extremities, Upper ▫ Right 528 (13.5) 12 799 66.1 ▫ Left 437 (11.2) 13 735 58.0 Extremities, Lower ▫ Right 622 (15.9) 9 869 71.6 ▫ Left 538 (13.8) 11 789 68.2 Total 11,669‡ 21,091§ 57.0//

* SOAP Note Form indicates Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form; OMT, osteopathic manipulative treatment. † Data for two regions (ie, Head and Face and T1 to T4) indicate that they have the same frequency and percentage of somatic dysfunction that improved with OMT. Therefore, both regions are ranked second. ‡ When the total number of cases improved with OMT (11,669) is divided by the number of regions treated (14), results indicate that there was an average of 833.5 cases resolved per region. In other words, for each patient, 21.3% of somatic dysfunctions in each region improved after treatment. § The total treated (21,091) is larger than the total number of cases (3908), indicating that an average of 5.3 regions were treated with OMT in each patient visit. // The percentage of somatic dysfunction improved, as reported, is an average value.

Dysfunctions of the pelvis were the most frequently Item 8: What is the incidence of diseases by ICD-9 code? resolved (26.2%) somatic dysfunctions reported, followed by For the present study, 24,161 separate cells of information lumbar (24.8%), thoracic T10 to T12 (24.3%), and sacral (24.3%) with ICD-9-CM code diagnoses were recorded in the database dysfunctions (Table 5). (Table 8), with up to 17 codes being recorded for one patient Somatic dysfunctions in the cervical region were those encounter, as happened in 10 cases. There were 520 individual most likely to be improved (36.7%), followed by head and ICD-9-CM codes used for diagnoses in this study. thoracic T1 to T4 (29.9% each) (Table 6). The most common ICD-9-CM diagnosis codes used by Item 7: What is the incidence of physician’s evaluation before OMT study participants were diseases of the musculoskeletal sys- for first visit: resolved, improved, unchanged, and worse? tems and connective tissue (89.22%); injury and poisoning Only 8% of patient encounters were with new patients or with (3.66%) (when the supplementary classification codes for external established patients with new complaints. causes of injury and poisoning [0.26%] were also included); For previously treated, established patients, evaluations symptoms, signs, and ill-defined conditions (1.54%); diseases of before current-visit treatment with OMT revealed that 23% the nervous system and sense organs (0.89%); and diseases of of patients felt their conditions had improved. Although 10% the digestive system and mental disorders (0.83% each) (Table 8). of patients reported that their conditions were unchanged, Item 9: What is the incidence of OMT performed and recorded for 5% reported that their conditions had worsened, and 1% of 1 to 2, 3 to 4, 5 to 6, 7 to 8, and 9 to 10 musculoskeletal body regions? patients reported that their complaints were resolved. The number of body regions most frequently treated with

192 • JAOA • Vol 105 • No 4 • April 2005 Sleszynski and Glonek • Original Contribution ORIGINAL CONTRIBUTION

Table 7 SOAP Note Form* Outcomes Research: Incidence of Somatic Dysfunction Unchanged with OMT by Body Region (N=3908)

Within-Region Group

Region Treated No. (%) Rank† Treated, No. Unchanged, %

Head and Face 8 (0.2) 4 1933 0.2 Cervical (Neck) 12 (0.3) 3 2176 0.5 Thoracic ▫ T1 to T4 13 (0.3) 3 2016 0.6 ▫ T5 to T9 14 (0.4) 2 1687 0.8 ▫ T10 to T12 11 (0.3) 3 1547 0.7 Ribs 15 (0.4) 2 1589 0.9 Lumbar 18 (0.5) 1 2015 0.9 Sacrum 7 (0.2) 4 1995 0.4 Pelvis 7 (0.2) 4 1871 0.3 Abdomen 3 (0.1) 5 1052 0.2 Extremities, Upper ▫ Right 11 (0.3) 3 799 1.4 ▫ Left 10 (0.3) 3 735 1.4 Extremities, Lower ▫ Right 15 (0.4) 2 869 1.7 ▫ Left 9 (0.2) 4 789 1.1 Total 153‡ 21,091§ 0.8//

* SOAP Note Form indicates Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form; OMT, osteopathic manipulative treatment. † Data for three regions (ie, T5 to T9, Ribs, and Lower Extremity, Right) indicate that they have the same frequency and percentage of somatic dysfunction that was unchanged with OMT. Therefore, all three regions are ranked second. In addition, data for five regions (ie, Cervical [Neck], T1 to T4, T10 to T12, and both Upper Extremities) have the same frequency and percentage and were all ranked third. Finally, data for four regions (ie, Head and Face, Sacrum, Pelvis, and Lower Extremity, Left) have the same frequency and percentage and were all ranked fourth. ‡ When the total number of cases unchanged with OMT (153) is divided by the number of regions treated (14), results indicate that there was an average of 10.9 cases unchanged per region. In other words, for each patient, 0.3% of somatic dysfunctions in each region were unchanged after treatment. § The total treated (21,091) is larger than the total number of cases (3908), indicating that an average of 5.3 regions were treated with OMT in each patient visit. // The percentage of somatic dysfunction unchanged, as reported, is an average value.

OMT was 7 to 8 (35.9%), followed by 9 to 10 (23.3%), and All body regions with somatic dysfunction severity ratings 5 to 6 (20.6%) (Table 9). were essentially equal (ie, rounded to 100%) to the OMT-per- Item 10: What is the most frequently recommended follow-up time? formed section of the musculoskeletal table (Table 1). When Study participants most commonly recommended that patients somatic dysfunction was present in this sample population, it return for a follow-up visit in one week. was treated with OMT. Moreover, the body regions for which OMT was per- Averages Questions formed equaled the number of regions marked in the “OMT performed as Above” section of the Outpatient Osteopathic Item 11: What is the average age of patients treated? Assessment and Plan Form (ie, fourth page of both the Data on patients’ ages were reported for 2070 (53%) subjects. SOS MSEF29 and the SNF-2E) and the second page of the Out- Among these subjects, the mean age was 43 years. patient Osteopathic SOAP Note—Follow-up Form. As noted Item 12: What is the average visit duration? in Tables 5 through 7, regions treated with OMT equaled 21,091 Patient visits lasted an average of 36 minutes. for 3908 patient visits, or an average of 5.3 regions evaluated Item 13: What was the average number of regions evaluated and/or and treated per patient visit. treated with OMT?

Sleszynski and Glonek • Original Contribution JAOA • Vol 105 • No 4 • April 2005 • 193 ORIGINAL CONTRIBUTION

Table 8 SOAP Note Form* Outcomes Research: ICD-9-CM Codes† Recorded by Group (N=3908)

ICD-9-CM Code General Diagnostic Group No. (%) Rank‡

001-139 Infectious and parasitic disease 24 (0.10) 14 140-239 Neoplasms 8 (0.03) 16 240-279 Endocrine, nutritional and metabolic diseases, and immunity disorders 126 (0.52) 7 280-289 Diseases of the blood and blood-forming organs 12 (0.05) 15 290-319 Mental disorders 201 (0.83) 5 320-389 Diseases of the nervous system and sense organs 216 (0.89) 4 390-459 Diseases of the circulatory system 81 (0.34) 10 460-519 Diseases of the respiratory system 170 (0.70) 6 520-579 Diseases of the digestive system 200 (0.83) 5 580-629 Diseases of the genitourinary system 47 (0.19) 13 630-676 Complications of pregnancy, childbirth, and the puerperium 2 (0.01) 17 680-709 Diseases of the skin and subcutaneous tissue 53 (0.22) 12 710-739 Diseases of the musculoskeletal system and connective tissue 21,556 (89.22) 1 740-759 Congenital anomalies 92 (0.38) 9 780-799 Symptoms, signs, and ill-defined conditions 371 (1.54) 3 800-999 Injury and poisoning 821 (3.40) 2 V01-V82 Supplementary classification of factors influencing health status and contact with health services 117 (0.48) 8 E800-E999 Supplementary classification of external causes of injury and poisoning 64 (0.26) 11 Total 24,161§

* SOAP Note Form indicates Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form. † Source: American Medical Association. ICD-9-CM 2002: International Classification of Diseases, Clinical Modification. Vols 1 and 2. 9th rev. 4th ed. Chicago, Ill: American Medical Association; 2001. ‡ Data for two diagnostic groups (ie, 290-319, Mental disorders and 520-579, Diseases of the digestive system) indicated that they have the same frequency and percentage of use by participating osteopathic physicians, residents, and undergraduate fellows in diagnosing subjects’ somatic dysfunctions. Therefore, both groups are ranked fifth. § Each of the 3908 subjects in the present study had multiple ICD-9-CM diagnoses recorded in SOAP Note Forms. As indicated, the total number of diagnoses made for this subject population was 24,161.

Correlations Questions 739.2, Thoracic region, for all five of the most commonly used Item 14: Was there a correlation between disease entity and spe- OM techniques (minimum count, maximum count): ▫ cific OM techniques used? articulatory, 435, 1279; ▫ As noted, the OM techniques most commonly used by study direct, 464, 1472; ▫ participants to treat subjects ranked in the following order: muscle energy, 491, 1741; ▫ articulatory and soft tissue (18% each), direct (15.4%), muscle myofascial release, 240, 1108; and ▫ energy (12.5%), and myofascial release (11.9%) (Table 4). soft tissue, 462, 1545. We further sought to determine whether any particular These five OM techniques were also most commonly used dysfunctions or disease entities at the highest severity level ( 44 times) by study participants for treating subjects with were treated preferentially using specific OM techniques the following ICD-9-CM codes specified in their medical records: ▫ (Table 10). In this study, the 739 ICD-9-CM numeric code series, 719.48, Diseases of the musculoskeletal system and con- Diseases of the musculoskeletal system and connective tissue – nective tissue — Arthropathies and related disorders – Other Osteopathies, chondropathies, and acquired musculoskeletal deformities and unspecified disorders of joint – Pain in joint – Arthralgia; ▫ – Nonallopathic lesions, not elsewhere classified (ie, all somatic 729.1, Diseases of the musculoskeletal system and connec- dysfunctions), were the most frequently encountered, with tive tissue – Rheumatism, excluding the back – Other disorders the lowest incidence of this diagnosis type corresponding to of soft tissues – Mylagia and myositis, unspecified (eg, code 739.9, Abdomen and other, and the maximum to code fibromyalgia), 194 • JAOA • Vol 105 • No 4 • April 2005 Sleszynski and Glonek • Original Contribution ORIGINAL CONTRIBUTION

▫ 847 codes, Injury and poisoning – Sprains and strains of joints and adjacent muscles – Sprains and strains of other and unspecified Table 9 parts of back, mainly neck (847.0) and thoracic (847.1). SOAP Note Form* Outcomes Research: Myofascial release was rarely used for diagnosis with Number of Body Regions Treated with OMT (N=3908) ICD-9-CM code 307.81, Mental disorders – Neurotic disorders, personality disorders, and other nonpsychotic mental disorders – Body Regions Subjects Receiving Special symptoms or syndromes, not elsewhere classified – Psy- Treated Per Subject OMT, No (%) chalgia – Tension headache (n=7). Myofascial release was also 0 7 (0.2) uncommon with two of the more common 847 codes, Injury 1 to 2 160 (5.1) and poisoning – Sprains and strains of joints and adjacent muscles 3 to 4 468 (14.9) – Sprains and strains of other and unspecified parts of back (ie, 5 to 6 648 (20.6) lumbar [847.2, n=39] and sacrum [847.3, n=18]). Myofascial release was commonly used, however, for the most common 7 to 8 1130 (35.9) ICD-9-CM 847 code, thoracic (847.1, n=78). 9 to 10 734 (23.3) Incidence for the use of myofascial release, direct, and Total 3147† (100) muscle energy for ICD-9-CM diagnosis code 719.45, Diseases of the musculoskeletal system and connective tissue – Arthropathies and * SOAP Note Form indicates Outpatient Osteopathic SOAP related disorders – Other and unspecified disorders of joint – Pain in (Subjective, Objective, Assessment, Plan) Note Form; OMT, osteopathic manipulative treatment. joint – Pelvic region and thigh was at 50 or greater. † The difference between subject population (3908) and the For diagnosis with the ICD-9-CM 723 codes, Diseases of the total number of subjects receiving OMT (3147), as indicated by body regions treated, indicates that not all subjects’ SOAP musculoskeletal system and connective tissue – Dorsopathies – Other Note Forms included documentation of OMT by body region. disorders of cervical region, muscle energy and myofascial release were frequently used by study participants to treat subjects with cervicalgia (723.1, n85). In the treatment of subjects with cervicocranial syndrome (723.2), participants most com- of muscle, liagament, and fascia – Spasm of muscle; monly used articulatory, muscle energy, and soft tissue tech- ▫ 729.1, Diseases of the musculoskeletal system and connec- niques (n72). tive tissue – Rheumatism, excluding the back – Other disorders Muscle energy and myofascial release were the most fre- of soft tissues – Mylagia and myositis, unspecified; quently used OM techniques used by participants treating ▫ 739 series, Osteopathies, chondropathies, and acquired muscu- subjects at the highest severity level with ICD-9-CM diagnosis loskeletal deformities – Nonallopathic lesions, not elsewhere classified: code 724.2, Diseases of the musculoskeletal system and connective head region (739.0), cervical region (739.1), thoracic region tissue – Dorsopathies – Other and unspecified disorders of the back (739.2), lumbar region (739.3), sacral region (739.4), pelvic – Lumbago (n76). region (739.5), lower extremities (739.6), upper extremities For ICD-9-CM diagnosis code 728.85, Diseases of the mus- (739.7), rib cage (739.8), and abdomen and other (739.9); and culoskeletal system and connective tissue – Rheumatism, excluding ▫ 847 codes, Injury and poisoning – Sprains and strains of joints the back – Disorders of muscle, liagament, and fascia – Spasm of and adjacent muscles – Sprains and strains of other and unspecified muscle, participants most commonly used articulatory, muscle parts of back, mainly: neck (847.0), thoracic region (847.1), lumbar energy, and soft tissue techniques (n62). region (847.2), and sacrum (847.3). Muscle energy was used by participants to treat subjects Item 15: Is there a correlation between severity of somatic dysfunc- with the most common diagnoses: tion and the response to treatment? ▫ 307.81, Mental disorders – Neurotic disorders, personality The severity of somatic dysfunction (scale = 0 [lowest], 1, 2, 3 disorders, and other nonpsychotic mental disorders – Special [highest]) for each body region and response to treatment symptoms or syndromes, not elsewhere classified – Tension (resolved, improved, unchanged, worse) were cross-tabulated, headache; and the significance of the results for the Spearman rank cor- ▫ 719 codes, Arthropathies and related disorders – Other and relation test (an ordinal-by-ordinal symmetric measure) was unspecified disorders of joint – Pain in joint, mainly: pelvic region determined for each body region. In this analysis, there was a and thigh (719.45) and arthralgia (719.48); correlation for the head, thoracic T10 to T12, lumbar, pelvic, ▫ 723 codes, Diseases of the musculoskeletal system and connective lower and upper extremities, ribs, abdomen (P.001), and tissue – Dorsopathies – Other disorders of cervical region, mainly: cervical regions (P=.001). There was not a correlation for tho- cervicalgia (723.1) and cervicocranial syndrome (723.2); racic T1 to T4 (P=.47), thoracic T5 to T9 (P=.10), and the sacrum ▫ 724.2, Diseases of the musculoskeletal system and connec- (P=.72) at the .05 level. tive tissue – Dorsopathies – Other and unspecified disorders Considering the three body regions that have the highest of the back – Lumbago; number of valid cases and high correlations—the thoracic T10 to ▫ 728.85, Diseases of the musculoskeletal system and con- T12 (n=1497, P=.44), lumbar (n=1938, P=.322), and rib (n=1530, nective tissue – Rheumatism, excluding the back – Disorders P=.22)—the thoracic T10 to T12 and ribs were primarily noted Sleszynski and Glonek • Original Contribution JAOA • Vol 105 • No 4 • April 2005 • 195 ORIGINAL CONTRIBUTION

Table 10 SOAP Note Form* Outcomes Research: Most Prevalent ICD-9-CM Codes† Indicated at the Highest Severity Level for All Treatment Methods (N=18,079)

Region Treated ICD-9-CM Code Diagnosis No. (%)

Head and Face (n=3575) 739.0 Nonallopathic lesions, not elsewhere classified–Head region 825 (23.1) 739.1 Nonallopathic lesions, not elsewhere classified–Cervical region 807 (22.6) 739.2 Nonallopathic lesions, not elsewhere classified–Thoracic region 790 (22.1) 739.3 Nonallopathic lesions, not elsewhere classified–Lumbar region 742 (20.1)

847.0 Sprains and strains of other and unspecified parts of back–Neck 105 (2.9) 847.1 Sprains and strains of other and unspecified parts of back–Thoracic region 105 (2.9) 723.2 Other disorders of cervical region–Cervicocranial syndrome 80 (2.2) 307.81 Special symptoms or syndromes, not elsewhere classified–Tension headache 67 (1.9) 729.1 Other disorders of soft tissues–Myalgia and myositis, unspecified 54 (1.5)

Cervical (Neck) (n=3898) 739.1 Nonallopathic lesions, not elsewhere classified–Cervical region 912 (23.4) 739.2 Nonallopathic lesions, not elsewhere classified–Thoracic region 883 (22.7) 739.0 Nonallopathic lesions, not elsewhere classified–Head region 818 (21.0) 739.3 Nonallopathic lesions, not elsewhere classified–Lumbar region 813 (20.9)

847.0 Sprains and strains of other and unspecified parts of back–Neck 162 (4.2) 847.1 Sprains and strains of other and unspecified parts of back–Thoracic region 117 (3.0) 729.1 Other disorders of soft tissues–Myalgia and myositis, unspecified 66 (1.7) 723.2 Other disorders of cervical region–Cervicocranial syndrome 65 (1.7) 847.2 Sprains and strains of other and unspecified parts of back–Lumbar region 62 (1.6)

continued...

as having been “improved” with OMT, whereas complaints vicalgia (723.1) and cervicocranial syndrome (723.2); with the lumbar region were noted as having been “resolved.” ▫ 724.2, Diseases of the musculoskeletal system and connec- Item 16: Is there a correlation between disease entity and the top 4 tive tissue – Dorsopathies – Other and unspecified disorders most severe body regions for somatic dysfunction? of the back – Lumbago; ▫ Other than the 739 ICD-9-CM numeric code series, Diseases of 728.85, Diseases of the musculoskeletal system and con- the musculoskeletal system and connective tissue – Osteopathies, nective tissue – Rheumatism, excluding the back – Disorders chondropathies, and acquired musculoskeletal deformities – Nonal- of muscle, liagament, and fascia – Spasm of muscle; ▫ lopathic lesions, not elsewhere classified (ie, all somatic dysfunc- 729.1, Diseases of the musculoskeletal system and connec- tions), the most common ICD-9-CM diagnosis codes reported tive tissue – Rheumatism, excluding the back – Other disorders for all body regions were as follows: of soft tissues – Mylagia and myositis, unspecified; and ▫ ▫ 307.81, Mental disorders – Neurotic disorders, personality 847 codes, Injury and poisoning – Sprains and strains of joints disorders, and other nonpsychotic mental disorders – Special and adjacent muscles – Sprains and strains of other and unspecified symptoms or syndromes, not elsewhere classified – Psychalgia parts of back, mainly neck (847.0), thoracic region (847.1), lumbar – Tension headache; region (847.2), and sacrum (847.3). ▫ 719 codes, Diseases of the musculoskeletal system and connective The dominant OM techniques used by participants were tissue – Arthropathies and related disorders – Other and unspecified cranial osteopathy (1829, 46.80%) and muscle energy (1785, disorders of joint – Pain in joint, mainly of the pelvic region and 45.68%). The cranial osteopathy technique was used primarily thigh (719.45) and also arthralgia (719.48); for treatment of the head (92.2%) whereas muscle energy was ▫ 723 codes, Diseases of the musculoskeletal system and connective used to treat all body regions: head, 17.3%; cervical, 15.9%; tissue – Dorsopathies – Other disorders of cervical region, mainly cer- T1 to T4, 22.1%; T5 to T9, 18.0%; T10 to T12, 14.2%; lumbar, 6.2%; sacral, 3.6%; pelvic, 1.7%; right upper extremity, 0.7%; and

196 • JAOA • Vol 105 • No 4 • April 2005 Sleszynski and Glonek • Original Contribution ORIGINAL CONTRIBUTION

Table 10 (Continued) SOAP Note Form* Outcomes Research: Most Prevalent ICD-9-CM Codes† Indicated at the Highest Severity Level for All Treatment Methods (N=18,079)

Region Treated ICD-9-CM Code Diagnosis No. (%)

Thoracic (n=6872) ▫ T1 to T4 (n=3275) 739.2 Nonallopathic lesions, not elsewhere classified–Thoracic region 767 (23.4) 739.1 Nonallopathic lesions, not elsewhere classified–Cervical region 741 (22.6) 739.3 Nonallopathic lesions, not elsewhere classified–Lumbar region 676 (20.6) 739.0 Nonallopathic lesions, not elsewhere classified–Head region 674 (20.6)

847.1 Sprains and strains of other and unspecified parts of back–Thoracic region 158 (4.8) 847.0 Sprains and strains of other and unspecified parts of back–Neck 101 (3.1) 847.2 Sprains and strains of other and unspecified parts of back–Lumbar region 53 (1.6) 729.1 Other disorders of soft tissues–Myalgia and myositis, unspecified 60 (1.8) 307.81 Special symptoms or syndromes, not elsewhere classified–Tension headache 45 (1.4)

▫ T5 to T9 (n=2717) 739.2 Nonallopathic lesions, not elsewhere classified–Thoracic region 624 (23.0) 739.1 Nonallopathic lesions, not elsewhere classified–Cervical region 600 (22.1) 739.3 Nonallopathic lesions, not elsewhere classified–Lumbar region 568 (20.9) 739.0 Nonallopathic lesions, not elsewhere classified–Head region 553 (20.3)

847.1 Sprains and strains of other and unspecified parts of back–Thoracic region 136 (5.0) 847.0 Sprains and strains of other and unspecified parts of back–Neck 90 (3.3) 729.1 Other disorders of soft tissues–Myalgia and myositis, unspecified 62 (2.3) 847.2 Sprains and strains of other and unspecified parts of back–Lumbar region 50 (1.8) 307.81 Special symptoms or syndromes, not elsewhere classified–Tension headache 34 (1.2)

▫ T10 to T12 (n=880) 739.2 Nonallopathic lesions, not elsewhere classified–Thoracic region 210 (23.9) 739.1 Nonallopathic lesions, not elsewhere classified–Cervical region 191 (21.7) 739.3 Nonallopathic lesions, not elsewhere classified–Lumbar region 190 (21.6) 739.0 Nonallopathic lesions, not elsewhere classified–Head region 173 (19.6)

847.1 Sprains and strains of other and unspecified parts of back–Thoracic region 38 (4.3) 729.1 Other disorders of soft tissues–Myalgia and myositis, unspecified 38 (4.3) 847.0 Sprains and strains of other and unspecified parts of back–Neck 15 (1.7) 728.85 Disorders of muscle, ligament, and fascia–Spasm of muscle 14 (1.6) 847.2 Sprains and strains of other and unspecified parts of back–Lumbar region 11 (1.2)

Lumbar (n=3734) 739.3 Nonallopathic lesions, not elsewhere classified–Lumbar region 860 (23.0) 739.2 Nonallopathic lesions, not elsewhere classified–Thoracic region 834 (22.3) 739.4 Nonallopathic lesions, not elsewhere classified–Sacral region 811 (21.7) 739.1 Nonallopathic lesions, not elsewhere classified–Cervical region 800 (21.4)

847.2 Sprains and strains of other and unspecified parts of back–Lumbar region 128 (3.4) 847.1 Sprains and strains of other and unspecified parts of back–Thoracic region 101 (2.7) 847.0 Sprains and strains of other and unspecified parts of back–Neck 90 (2.4) 728.85 Disorders of muscle, ligament, and fascia–Spasm of muscle 57 (1.5) 729.1 Other disorders of soft tissues–Myalgia and myositis, unspecified 53 (1.4)

the remainder of regions accounted for less than 0.1%. where the highest severity rating was most prevalent—were The body regions in which the greatest incidence of the head (mean severity level SE [standard error], somatic dysfunction was found by study participants—that is, 2.20 0.017), cervical (2.169 0.016), thoracic (T1 to T4,

Sleszynski and Glonek • Original Contribution JAOA • Vol 105 • No 4 • April 2005 • 197 ORIGINAL CONTRIBUTION

Table 11 SOAP Note Form* Outcomes Research: Most Prevalent ICD-9-CM Codes† Indicated at the Highest Severity Level for OMT Muscle Energy Technique (N=6933)

Region Treated ICD-9-CM Code Diagnosis No. (%)

Head and Face (n=694) 739.0 Nonallopathic lesions, not elsewhere classified–Head region 154 (22.2) 739.2 Nonallopathic lesions, not elsewhere classified–Thoracic region 150 (21.6) 739.1 Nonallopathic lesions, not elsewhere classified–Cervical region 148 (21.3) 739.3 Nonallopathic lesions, not elsewhere classified–Lumbar region 138 (19.9)

847.0 Sprains and strains of other and unspecified parts of back–Neck 30 (4.3) 847.1 Sprains and strains of other and unspecified parts of back–Thoracic region 24 (3.5) 723.2 Other disorders of cervical region–Cervicocranial syndrome 22 (3.2) 307.81 Special symptoms or syndromes, not elsewhere classified–Tension headache 18 (2.6) 728.85 Disorders of muscle, ligament, and fascia–Spasm of muscle 10 (1.4)

Cervical (Neck) (n=2844) 739.1 Nonallopathic lesions, not elsewhere classified–Cervical region 646 (22.7) 739.2 Nonallopathic lesions, not elsewhere classified–Thoracic region 634 (22.3) 739.3 Nonallopathic lesions, not elsewhere classified–Lumbar region 606 (21.3) 739.4 Nonallopathic lesions, not elsewhere classified–Sacral region 586 (20.6)

847.0 Sprains and strains of other and unspecified parts of back–Neck 139 (4.9) 847.1 Sprains and strains of other and unspecified parts of back–Thoracic region 90 (3.2) 847.2 Sprains and strains of other and unspecified parts of back–Lumbar region 53 (1.9) 723.2 Other disorders of cervical region–Cervicocranial syndrome 52 (1.8) 307.81 Special symptoms or syndromes, not elsewhere classified–Tension headache 38 (1.3)

continued...

* SOAP Note Form indicates Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form; OMT, osteopathic manipulative treatment. † Source: American Medical Association. ICD-9-CM 2002: International Classification of Diseases, Clinical Modification. Vols 1 and 2. 9th rev. 4th ed. Chicago, Ill: American Medical Association; 2001. The top four 739 ICD-9-CM 2002 codes and the top five Other codes are provided in this table. More information is available on request from the author.

2.115 0.017; T5 to T9, 2.068 0.019; T10 to T12, 1.570 0.019), symptoms or syndromes, not elsewhere classified – Psychalgia and lumbar (2.125 0.018) (Table 10). – Tension headache. The dominant ICD-9-CM diagnosis codes for these body In Table 11, the same analysis is presented but only for regions are, as noted elsewhere, the 739 ICD-9-CM numeric cases in which the muscle energy technique was used when code series, Diseases of the musculoskeletal system and connective participants provided OMT. The distribution of ICD-9-CM tissue – Osteopathies, chondropathies, and acquired musculoskeletal numeric codes under these restrictions is essentially the same deformities – Nonallopathic lesions, not elsewhere classified, mainly when data are not separated for this particular OM technique of the following body regions: head (739.0), cervical (739.1), tho- (Table 10); however, this data restriction does reduce the inci- racic (739.2), and lumbar (739.3). Other dominant codes are: dence of dysfunction recorded for each body region. The dis- ▫ 847 codes, Injury and poisoning – Sprains and strains of joints tribution of other ICD-9-CM codes was altered between these and adjacent muscles – Sprains and strains of other and unspecified outcome sets with, for example, the increased prominence of parts of back, mainly of the neck (847.0) thoracic (847.1), and 728.85, Diseases of the musculoskeletal system and connective lumbar (847.2 ) regions; tissue – Rheumatism, excluding the back – Disorders of muscle, ▫ 729.1, Diseases of the musculoskeletal system and connec- liagament, and fascia – Spasm of muscle. tive tissue – Rheumatism, excluding the back – Other disorders For all body regions, the dominant response to treatment of soft tissues – Mylagia and myositis, unspecified; and was “improved” (head, 10.93%; cervical, 14.72%; T1 to T4, ▫ 307.81, Mental disorders – Neurotic disorders, personality 13.47%; T5 to T9, 11.09%; T10 to T12, 13.18%; sacral, 9.09%), disorders, and other nonpsychotic mental disorders – Special indicating that the OM muscle energy technique is a clinically efficacious treatment option in this population.

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Table 11 (Continued) SOAP Note Form* Outcomes Research: Most Prevalent ICD-9-CM Codes† Indicated at the Highest Severity Level for OMT Muscle Energy Technique (N=6933)

Region Treated ICD-9-CM Code Diagnosis No. (%)

Thoracic (n=425) ▫ T1 to T4 (n=169) 739.1 Nonallopathic lesions, not elsewhere classified–Cervical region 39 (23.1) 739.2 Nonallopathic lesions, not elsewhere classified–Thoracic region 39 (23.1) 739.0 Nonallopathic lesions, not elsewhere classified–Head region 29 (17.2) 739.3 Nonallopathic lesions, not elsewhere classified–Lumbar region 29 (17.2)

847.1 Sprains and strains of other and unspecified parts of back–Thoracic 12 (7.1) 847.0 Sprains and strains of other and unspecified parts of back–Neck 10 (5.9) 729.1 Other disorders of soft tissues–Myalgia and myositis, unspecified 5 (3.0) 728.85 Disorders of muscle, ligament, and fascia–Spasm of muscle 3 (1.8) 723.1 Other disorders of cervical region–Cervicalgia 3 (1.8)

▫ T5 to T9 (n=160) 739.1 Nonallopathic lesions, not elsewhere classified–Cervical region 34 (21.2) 739.2 Nonallopathic lesions, not elsewhere classified–Thoracic region 32 (20.0) 739.0 Nonallopathic lesions, not elsewhere classified–Head region 31 (19.4) 739.3 Nonallopathic lesions, not elsewhere classified–Lumbar region 29 (18.1)

847.0 Sprains and strains of other and unspecified parts of back–Neck 10 (6.2) 847.1 Sprains and strains of other and unspecified parts of back–Thoracic region 10 (6.2) 728.85 Disorders of muscle, ligament, and fascia–Spasm of muscle 6 (3.7) 729.1 Other disorders of soft tissues–Myalgia and myositis, unspecified 5 (3.1) 728.5 Disorders of muscle, ligament, and fascia–Hypermobility syndrome 3 (1.9)

▫ T10 to T12 (n=96) 739.1 Nonallopathic lesions, not elsewhere classified–Cervical region 24 (25.0) 739.2 Nonallopathic lesions, not elsewhere classified–Thoracic region 20 (21.3) 739.3 Nonallopathic lesions, not elsewhere classified–Lumbar region 19 (19.8) 739.0 Nonallopathic lesions, not elsewhere classified–Head region 18 (18.7)

847.1 Sprains and strains of other and unspecified parts of back–Thoracic region 5 (5.2) 847.2 Sprains and strains of other and unspecified parts of back–Lumbar region 3 (3.1) 729.1 Other disorders of soft tissues–Myalgia and myositis, unspecified 3 (3.1) 719.45 Diseases of the musculoskeletal system and connective tissue– 2 (2.1) Arthropathies and related disorders– Other and unspecified disorders of joint – Pain in joint – Pelvic region and thigh 719.48 Other and unspecified disorders of joint–pain in joint–other 2 (2.1) specified sites

Lumbar (n=2970) 739.3 Nonallopathic lesions, not elsewhere classified–Lumbar region 671 (22.6) 739.2 Nonallopathic lesions, not elsewhere classified–Thoracic region 656 (22.1) 739.4 Nonallopathic lesions, not elsewhere classified–Sacral region 648 (21.8) 739.1 Nonallopathic lesions, not elsewhere classified–Cervical region 635 (21.4)

847.2 Sprains and strains of other and unspecified parts of back–Lumbar region 115 (3.9) 847.1 Sprains and strains of other and unspecified parts of back–Thoracic region 83 (2.8) 847.0 Sprains and strains of other and unspecified parts of back–Neck 75 (2.5) 723.2 Other disorders of cervical region–Cervicocranial syndrome 46 (1.5) 728.85 Disorders of muscle, ligament, and fascia–Spasm of muscle 41 (1.4)

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Differences Question loskeletal deformities – Nonallopathic lesions, not elsewhere classified, Item 17: What are the most frequently diagnosed and treated regions specifically of the thoracic (739.2) and cervical (739.1) regions. among providers? The OMT procedures residents used in association with For 7 of 10 participating osteopathic physicians, residents, and treating patients with these dysfunctions could easily be undergraduate fellows, the most commonly used diagnoses obtained from the compiled data as well—as could the number were two of the 739 codes, Diseases of the musculoskeletal system of body regions treated. Residents could be easily tracked for and connective tissue – Osteopathies, chondropathies, and acquired mus- parameters used to test resident competency, such as numbers culoskeletal deformities – Nonallopathic lesions, not elsewhere classi- of patients with certain diagnoses seen or specific procedures fied, specifically in the thoracic (739.2) and cervical (739.1) regions. (eg, OM techniques) performed. With data obtained through The cervical region code (739.1) had the second highest participant-submitted SNFs, questions such as “How many incidence of use, as reported by 8 of 10 participants, and was patients have an elevation in blood pressure parameters but were treated with OMT almost every time it was diagnosed. The not diagnosed with hypertension?“ can be answered. thoracics were treated with OMT only 49.6% of the time. This Many questions specific to a selected physician’s prac- disparity in the use of OMT between similarly diagnosed con- tice could also be examined, for example: Which OM tech- ditions in different body regions suggests that, at least among niques does a particular osteopathic physician use most com- this group of osteopathic physicians, residents, and under- monly? What is the average number of body regions per graduate fellows, somatic dysfunction of the thoracic region is patient visit that a particular osteopathic physician treats with treated with OMT less frequently than that of the cervical region. OMT? What is the patient response rate to OMT that a particular osteopathic physician has by body region? What is the Comment particular osteopathic physician’s patient-improvement rate A valid, standardized, and easily incorporated osteopathic after he or she provides OMT? form is essential for documenting the incidence, symptom This trial involved 17 specific outcomes questions (Figure 3) severity, treatment methods, and related outcomes of and for that are now open for discussion among the osteopathic med- management of musculoskeletal dysfunction in osteopathic ical profession. The groundwork laid down by the SNF pro- medical practices. Such a form is vital to the development of vides osteopathic physicians with a system for extracting the osteopathic medical profession for describing osteopathic answers to all of the questions posed—and has the potential practice standards and rationalizing OPP to the medical, legal, to provide answers to many more outcomes-based questions. and insurance communities. Standardized use of the SNF allowed researchers to extract Only through valid and consistent documentation can the large amounts of data in a relatively quick and simple way in osteopathic medical profession hope to obtain the necessary out- support of OPP. Based on evidence from the present study, we comes results that are now medical industry standards. encourage further development of the proposed SNF EV, The SNF is a validated,26 standardized form that has been which would greatly contribute to streamlining the process of proven in the present study to allow osteopathic physicians to centralized data collection for osteopathic researchers. effectively document frequency, severity, treatment, and related outcomes data in their management of musculoskeletal com- Acknowledgments plaints among their patient populations. The authors thank the following colleagues for their participation in this project: David S. Abend, DO; Michael S. Carnes, DO; Jerry L. Using the SNF, a diverse group of physicians from several Dickey, DO; Russell G. Gamber, DO, MPH; Eric E. Gish, DO; geographic regions with different types of practices and trained Bernadette Goheen Kohn, DO; R. Paul Lee, DO; Scott T. Stoll, DO, and certified in the use of the SOS-FS was able to submit data PhD; and Stuart F. Williams, DO. The authors also thank the 189 to a central data-collection site where investigators could obtain osteopathic residents and undergraduate fellows at UNTHSC as well useful outcomes-related data easily and efficiently. as the seven residents from the other study sites combined. The present study suggests that the application of the The authors recognize the contributions of William L. Kuchera, SNF to professional education assessment settings could sub- DO, who served as a consultant, composing the SNF forms and stantially streamline current processes. Tracking the educa- assisting in database construction. tional process would be simplified through the use of a stan- The authors also thank the following people for assisting with data dard tool that provides outcomes-based data. entry: Nancy Barbion, Sean Jaquish, Todd-Michael Larsen, Bethany For example, from the data collected in the present study, Mondrawickas, Kenneth O. Polzin III, Yolanda Sanders, Brian T. Sleszynski, Cynthia L. Sleszynski, and Katherine A. Sleszynski. a method for extracting data for residents was successful. Five residents were selected and the ICD-9-CM codes they used were tabulated. Numbers of cases, numbers of ICD-9-CM codes, and frequencies of codes chosen were reviewed. Among this group, the most frequent diagnoses encountered were two 739 codes, Diseases of the musculoskeletal system and connective tissue – Osteopathies, chondropathies, and acquired muscu-

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References 26. Sleszynski SL, Glonek T, Kuchera WA. Standardized medical record: a 1. Gevitz N. ‘Parallel and distinctive’: the philosophic pathway for reform in new outpatient osteopathic SOAP note form: validation of a standardized osteopathic medical education [review]. J Am Osteopath Assoc. office form against physician’s progress notes. J Am Osteopath Assoc. 1994;94:328–332. 1999;10:516–529. Abstract available at: http://www.jaoa.org/cgi/content/ 2. Dolin RH. Outcome analysis: considerations for an electronic health record abstract/99/10/516. Accessed April 26, 2005. [review]. MD Comput. 1997;14:50–56. 27. American Academy of Osteopathy. SOAP Note availability expands [news 3. Ware JE, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF- item]. AAO Newsletter. May 2004:9. 36). Part I: Conceptual framework and item selection. Med Care. 28. Nelson KE, Glonek T. Computer/Outcomes: hardcopy SOAP Note pre- 1992;30:473–481. liminary report. Fam Physician. August 1999;3:8–10. 4. Carey RM, Engelhard CL. Academic medicine meets managed care: A 29. Sleszynski SL, Glonek T, Kuchera WA. Outpatient osteopathic single high-impact collision. Acad Med. 1996;71:839–845. organ system musculoskeletal exam form: training and certification. JAm 5. McCormick KA, Cummings MA, Kovner C. The role of the Agency for Osteopath Assoc. 2004;104:76–81. Available at: http://www.jaoa.org/cgi/con- Health Care Policy and Research (AHCPR) in improving outcomes of care tent/full/104/10/423. Accessed April 26, 2005. [review]. Nurs Clin North Am. 1997;32:521–542. 30. American Academy of Osteopathy Outpatient Osteopathic SOAP Note 6. Owens DK. Use of medical informatics to implement and develop clinical Form Series and Usage Guide. 2nd ed. Indianapolis, Ind: American Academy practice guidelines. West J Med. 1998;168:166–175. of Osteopathy; 2002. Available at: http://www.academyofosteopathy.org/1. 7. Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S. A %20Form%20Series%20Usage%20Guide.pdf. Accessed May 9, 2005. comparison of osteopathic spinal manipulation with standard care for patients 31. Sleszynski SL, Glonek T. The standardized medical record. In: Nelson KE, with low back pain [published correction appears in N Engl J Med. ed. Osteopathic Considerations in Family Practice. Malden, Mass: Blackwell Pub- 2000;342:817]. N Engl J Med. 1999;341:1426–1431. Available at: http://con- lishing. In press. tent.nejm.org/cgi/content/abstract/341/19/1426. Accessed May 17, 2005. 32. American Academy of Osteopathy. Committee publishes Cranial SOAP 8. Bergman GJ, Winters JC, Groenier KH, Pool JJ, Meyboom-de Jong B, Note [news item]. AAO Newsletter. January 2005:11. Postema K, et al. Manipulative therapy in addition to usual medical care for 33. Korr IM. Osteopathic research: the needed paradigm shift [review]. JAm patients with shoulder dysfunction and pain: a randomized, controlled trial. Osteopath Assoc. 1991;91:161–168,170–171. Ann Intern Med. 2004;141:432–439. Available at: http://www.annals.org/ 34. Ross-Lee B, Weiser MA. Healthcare regulation: past, present and future. cgi/reprint/141/6/432.pdf. Accessed May 17, 2005. J Am Osteopath Assoc. 1994;94:74–78, 82–84. 9. Lipton JA, Meneses P, Martin JB, Mizera AC, Kappler R, Brooks JS, et al. 35. American Medical Association. ICD-9-CM 2002: International Classifica- Improved pain score outcomes achieved through the cooperative and cost- tion of Diseases, Clinical Modification. Vols 1 and 2. 9th rev. 4th ed. Chicago, effective use of physical (osteopathic manipulative) medicine in the treatment Ill: American Medical Association; 2001. of outpatient musculoskeletal complaints. AAO J. January 2002;12:26–32. 36. Frank L. Epidemiology. The epidemiologist’s dream: Denmark. Science. 10. Kelso AF. Records to assist osteopathic physicians. J Am Osteopath Assoc. 2003;301:163. 1975;74:751–754. 37. Evidence-Based Medicine Working Group. Evidence-based medicine. A 11. Seffinger MA, Najm WI, Mishra SI, Adams A, Dickerson VM, Murphy LS, new approach to teaching the practice of medicine. JAMA. et al. Reliability of spinal palpation for diagnosis of back and neck pain: a sys- 1992;268:2420–2425. tematic review of the literature. Spine. 2004;29:E413–E425. 38. Michaud GC, McGowan SL, van der Jagt RH, Dugan AK, Tugwell P. The 12. Weed LL. Medical records that guide and teach. N Engl J Med. introduction of evidence-based medicine as a component of daily practice. Bull 1968;278:652–657. Med Libr Assoc. 1996;84:478–481. Available at: http://www.pubmedcen- 13. Weed LL. Medical Records, Medical Education, and Patient Care: The tral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=8913549. Accessed Problem-Oriented Medical Record as a Basic Tool. Cleveland, Ohio: The Press April 26, 2005. of Case Western Reserve University; 1969. 39. Nelson KE, Glonek T. Computerization of medicine boosts productivity: 14. Weed LL. Implementing the Problem-Oriented Record. 2nd ed. Seattle, Efficiency in handling bureaucracy is key to improving practice management. Wash: Medical Computer Services Association; 1976. Osteopath Fam Physician News. March 2004;4:1,16–17. 15. Friedman HD, Johnston WL, Kelso AF, Schwartz FN. Effects of an edu- 40. Kappler RE, Larson NJ, Kelso AF. A comparison of osteopathic findings cational intervention on quality and frequency of osteopathic structural doc- on hospitalized patients obtained by trained student examiners and experi- umentation on hospital admitting examination [abstract]. J Am Osteopathic enced osteopathic physicians [abstract]. J Am Osteopath Assoc. Assoc. 1990;90:840. 1971;70:1091–1092. 16. Seffinger MA, Friedman HD, Johnston WL. Standardization of the hospital record for osteopathic structural examination: recording of musculoskeletal findings and somatic dysfunction diagnosis. J Am Osteopath Assoc. 1995;95:90–96. 17. Chila AG. Aspects of osteopathic clinical research. Osteopath Ann. 1983;11:292–293. 18. Chila AG. Research in manipulative therapy. Osteopath Ann. 1983;11:294–295. 19. Ward RC. Research in osteopathic practice: many dilemmas and some opportunities. Osteopath Ann. 1983;11:296–299. 20. Patterson MM. Osteopathic research: wither or whither? Osteopath Ann. 1983;11:300–305. 21. Harakal JH. Research and practice: a common ground. Osteopath Ann. 1983;11:306–307. 22. Chila AG. Somatic dysfunction as the independent variable in clinical research. Osteopath Ann. 1983;11:308–311. 23. Measel JW Jr. A team approach to clinical research. Osteopath Ann. 1983;11:312–314. 24. Sinclair RJ. Conducting research with an osteopathic physician: problems and possible solutions. Osteopath Ann. 1983;11:315–317. 25. Upledger JE. Craniosacral function in brain dysfunction. Osteopath Ann. 1983;11:318–324.

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Appendix – Part 1. Sample of the second edition of the Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form Series (SNF-2E).30 This is the SOAP Note Form in current use. This form series consists of four pages. The first page is a detailed Outpatient Health Summary form used for noting initial and on-going history. It is placed on the left side of most charts for easy accessibility. (Reprinted with permission of the American Academy of Osteopathy.) Copies of the Outpatient Osteopathic SOAP Note Form can be obtained from the Amer- ican Academy of Osteopathy, 3500 DePauw Blvd, Ste 1080, Indianapolis, IN 46268-1136; telephone: (317) 879-1881. This form series is also available online at http://www.academyofosteopathy.org/research_soap.cfm in a PDF (portable document format) file.

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Appendix – Part 2 (1 of 3). Sample of the second edition of the Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form Series (SNF-2E).30 This is the SOAP Note Form in current use. This form series consists of four pages, where pages 2 through 4 are used for each patient visit as physician progress notes. Page 1 of 3 is the Outpatient Osteopathic SOAP Note History Form and is used to document the chief complaint; to record a detailed review of systems; and to note personal past medical, family, and social history, as well as objective findings. (Reprinted with permission of the American Academy of Osteopathy.) Copies of the Outpatient Osteopathic SOAP Note Form can be obtained from the American Academy of Osteopathy, 3500 DePauw Blvd, Ste 1080, Indianapolis, IN 46268-1136; telephone: (317) 879-1881. This form series is also available online at http://www.academyofosteopathy.org/research_soap.cfm in a PDF (portable document format) file.

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Appendix – Part 2 (2 of 3). Sample of the second edition of the Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form Series (SNF-2E).30 This is the SOAP Note Form in current use. This form series consists of four pages, where pages 2 through 4 are used for each patient visit as physician progress notes. Page 2 of 3 is the Outpatient Osteopathic SOAP Note Exam Form and contains a musculoskeletal examination table and additional objective examination items. (Reprinted with permission of the American Academy of Osteopathy.) Copies of the Outpatient Osteopathic SOAP Note Form can be obtained from the American Academy of Osteopathy, 3500 DePauw Blvd, Ste 1080, Indianapolis, IN 46268-1136; telephone: (317) 879-1881. This form series is also available online at http://www.academyofosteopathy.org/ research_soap.cfm in a PDF (portable document format) file.

204 • JAOA • Vol 105 • No 4 • April 2005 Sleszynski and Glonek • Original Contribution ORIGINAL CONTRIBUTION

Appendix – Part 2 (3 of 3). Sample of the second edition of the Outpatient Osteopathic SOAP (Subjective, Objective, Assessment, Plan) Note Form Series (SNF-2E).30 This is the SOAP Note Form in current use. This form series consists of four pages, where pages 2 through 4 are used for each patient visit as physician progress notes. Page 3 of 3 is the Outpatient Osteopathic Assessment and Plan Form and contains prioritized diagnoses, treatment recommendations, and treatment(s) given. (Reprinted with permission of the American Academy of Osteopathy.) Copies of the Outpatient Osteopathic SOAP Note Form can be obtained from the American Academy of Osteopathy, 3500 DePauw Blvd, Ste 1080, Indianapolis, IN 46268-1136; telephone: (317) 879-1881. This form series is also available online at http://www.academyofosteopathy.org/research_soap.cfm in a PDF (portable document format) file.

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