Documentation patterns before cataract surgery at ten academic centers

Purpose: To determine the adequacy of documenting the preoperative evaluation for cataract surgery using criteria derived from published practice guidelines. Methods: 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. Results: 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. Conclusion: 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.