Documentation patterns before cataract surgery at ten academic centers

P P Lee; L Hilborne; L McDonald; J K Tobacman; H Kolder; T Johnson; R H Brook

doi:10.1016/S0161-6420(96)30525-3

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Documentation patterns before cataract surgery at ten academic centers

Journal article

Peer reviewed

Documentation patterns before cataract surgery at ten academic centers

P P Lee, L Hilborne, L McDonald, J K Tobacman, H Kolder, T Johnson and R H Brook

Ophthalmology (Rochester, Minn.), Vol.103(8), pp.1179-1183

08/1996

DOI: 10.1016/S0161-6420(96)30525-3

PMID: 8764784

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Abstract

To determine the adequacy of documenting the preoperative evaluation for cataract surgery using criteria derived from published practice guidelines. In 1990, 1139 surgeries that were performed on 1139 patients at ten institutions of the Academic Medical Center Consortium were reviewed for completeness of documentation of the preoperative evaluation. Criteria for completeness were derived from the American Academy of Ophthalmology Preferred Practice Pattern on cataract evaluation and the Agency for Health Care Policy and Research-sponsored guidelines. Twenty-six percent of charts lacked documentation of at least one of four basic elements of the preoperative evaluation. These four elements are (1) vision in the surgical eye; (2) vision in the fellow eye; (3) evaluation of the fundus, macula, or visual potential in the surgical eye: and (4) presence of some form (general or specific) of functional visual impairment. If, as stated in the guideline, a specific deficit in visual functioning should be identified, then 40% of charts fail to meet criteria. Documentation of the ocular preoperative assessment for cataract surgery is inadequate in more than one quarter of cases. The relation between lack of documentation and incompleteness of the examination is unknown. Improved documentation is needed to better measure and enhance the quality of care.

Cataract Extraction - standards

Macula Lutea

Cataract - diagnosis

Practice Guidelines as Topic - standards

United States

Humans

Medical Records

United States Agency for Healthcare Research and Quality

Academic Medical Centers - standards

Vision Disorders - diagnosis

Vision Disorders - physiopathology

Vision, Ocular - physiology

Societies, Medical

Cataract - physiopathology

Fundus Oculi

Visual Acuity - physiology

Details

Title: Subtitle: Documentation patterns before cataract surgery at ten academic centers
Creators: P P Lee - RAND, Health Sciences Program, Santa Monica, USA
L Hilborne
L McDonald
J K Tobacman
H Kolder
T Johnson
R H Brook
Resource Type: Journal article
Publication Details: Ophthalmology (Rochester, Minn.), Vol.103(8), pp.1179-1183
Publisher: United States
DOI: 10.1016/S0161-6420(96)30525-3
PMID: 8764784
ISSN: 0161-6420
eISSN: 1549-4713
Language: English
Date published: 08/1996
Academic Unit: Ophthalmology and Visual Sciences
Record Identifier: 9983980396702771

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