DOCUMENTATION PATTERNS BEFORE CATARACT-SURGERY AT 10 ACADEMIC CENTERS

Purpose: To determine the adequacy of documenting the preoperative eva luation for cataract surgery using criteria derived from published pra ctice guidelines. Methods: In 1990, 1139 surgeries that were performed on 1139 patients at ten institutions of the Academic Medical Center C onsortium were reviewed for completeness of documentation of the preop erative evaluation. Criteria for completeness were derived from the Am erican Academy of Ophthalmology Preferred Practice Pattern on cataract evaluation and the Agency for Health Care Policy and Research-sponsor ed guidelines. Results: Twenty-six percent of charts lacked documentat ion of at least one of four basic elements of the preoperative evaluat ion. These four elements are (1) vision in the surgical eye; (2) visio n in the fellow eye; (3) evaluation of the fundus, macula, or visual p otential in the surgical eye; and (4) presence of some form (general o r specific) of functional visual impairment, if, as stated in the guid eline, a specific deficit in visual functioning should be identified, then 40% of charts fail to meet criteria. Conclusion: Documentation of the ocular preoperative assessment for cataract surgery is inadequate in more than one quarter of cases. The relation between lack of docum entation and incompleteness of the examination is unknown, Improved do cumentation is needed to better measure and enhance the quality of car e.