Can history and physical examination be used as markers of quality? An analysis of the initial visit note in musculoskeletal care

BACKGROUND. The medical record serves as an important source of information regarding the care process, but few studies have examined whether thorough ness of documentation is associated with outcomes. OBJECTIVE. The objectives of this study were to analyze the initial visit n ote for 513 patients presenting with acute musculoskeletal pain compare tho roughness of documentation by physician specialty, and determine whether th oroughness of documentation was associated with clinical improvement or pat ient satisfaction. METHODS. A structured medical record abstraction was performed to examine w hether treating physicians documented key historical and physical exam find ings. Satisfaction with care, symptom relief, and functional improvement we re assessed after 3 months with validated survey instruments. RESULTS. In the initial visit note, 43 +/- 16% of selected historical findi ngs and 28 +/- 17% of physical examination findings were documented. Orthop edic surgeons documented 2 to 4 more historical and physical examination it ems (P < 0.01) and assigned more specific diagnoses (P < 0.01) than rheumat ologists and general internists. Multivariate models showed a very weak ass ociation between all aspects of documentation and patient satisfaction with the provider-patient interaction (all partial R-2 < 0.016) and no associat ion between documentation and 3-month pain relief or functional status. Pat ients' perception of physician communication was more highly associated wit h patient satisfaction (P = 0.0001) than was documentation. CONCLUSIONS. NO provider types consistently documented many important histo rical items and physical examination findings. While thoroughness of docume ntation was not associated with clinical outcomes, there was a very weak re lationship between documentation and patient satisfaction with provider-pat ient interactions.