Can History and Physical Examination Be Used as Markers of Quality?

Abstract

The medical record serves as an important source of information regarding the care process, but few studies have examined whether thoroughness of documentation is associated with outcomes. The objectives of this study were to analyze the initial visit note for 513 patients presenting with acute musculoskeletal pain, compare thoroughness of documentation by physician specialty, and determine whether thoroughness of documentation was associated with clinical improvement or patient satisfaction. A structured medical record abstraction was performed to examine whether treating physicians documented key historical and physical exam findings. Satisfaction with care, symptom relief, and functional improvement were assessed after 3 months with validated survey instruments. In the initial visit note, 43 ± 16% of selected historical findings and 28 ± 17% of physical examination findings were documented. Orthopedic surgeons documented 2 to 4 more historical and physical examination items (P Conclusions. No provider types consistently documented many important historical items and physical examination findings. While thoroughness of documentation was not associated with clinical outcomes, there was a very weak relationship between documentation and patient satisfaction with provider-patient interactions.