Lee P P, Hilborne L, McDonald L, Tobacman J K, Kolder H, Johnson T, Brook R H
RAND, Health Sciences Program, Santa Monica, USA.
Ophthalmology. 1996 Aug;103(8):1179-83. doi: 10.1016/s0161-6420(96)30525-3.
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.
使用从已发表的实践指南中得出的标准，确定白内障手术术前评估记录的充分性。
1990年，对学术医学中心联盟十个机构的1139例患者进行的1139例手术的术前评估记录完整性进行了审查。完整性标准源自美国眼科学会关于白内障评估的首选实践模式以及医疗保健政策与研究机构赞助的指南。
26%的病历缺少术前评估四个基本要素中至少一项的记录。这四个要素是：（1）患眼视力；（2）对侧眼视力；（3）患眼的眼底、黄斑或视觉潜能评估；（4）某种形式（一般或特定）的功能性视力损害的存在。如果按照指南所述应确定视觉功能的特定缺陷，那么40%的病历不符合标准。
超过四分之一的白内障手术眼部术前评估记录不充分。记录缺失与检查不完整之间的关系尚不清楚。需要改进记录以更好地衡量和提高护理质量。
