Documentation Patterns Before Cataract Surgery at Ten Academic Centers

The purpose of this study was to determine the adequacy of documenting the preoperative evaluation for cataract surgery using criteria derived from published practice guidelines. In 1990, 1,139 surgeries at ten institutions of the Academic Medical Center Consortium were reviewed for completeness of documentation of the preoperative evaluation using criteria 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: (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. Although the relation between lack of documentation and incompleteness of the examination is unknown, improved documentation is needed to measure the quality of care.