Documentation Patterns Before Cataract Surgery at Ten Academic Centers

Published In: Ophthalmology, v. 103, no. 8, Aug. 1996, p. 1179-1183

Posted on RAND.org on January 01, 1996

by Paul Lee, Lee H. Hilborne, Laurie L. McDonald, Joanne Tobacman, Hansjoerg Kolder, Tim Johnson, Robert H. Brook

Read More

Access further information on this document at www.aaojournal.org

This article was published outside of RAND. The full text of the article can be found at the link above.

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.

This report is part of the RAND Corporation External publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

Our mission to help improve policy and decisionmaking through research and analysis is enabled through our core values of quality and objectivity and our unwavering commitment to the highest level of integrity and ethical behavior. To help ensure our research and analysis are rigorous, objective, and nonpartisan, we subject our research publications to a robust and exacting quality-assurance process; avoid both the appearance and reality of financial and other conflicts of interest through staff training, project screening, and a policy of mandatory disclosure; and pursue transparency in our research engagements through our commitment to the open publication of our research findings and recommendations, disclosure of the source of funding of published research, and policies to ensure intellectual independence. For more information, visit www.rand.org/about/principles.

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.