Cataract: Lessons learned
December 2023

by Liz Hillman
Editorial Co-Director

Despite best efforts, medical documentation errors happen, both on paper charts and electronic files. The consequences of some of these errors can have ranging effects on patients and the practice.

From a patient standpoint, Dagny Zhu, MD, and John Bartlett, MD, shared several ways that this could affect outcomes and patient satisfaction. Steve Christensen said, “Documentation errors have the potential of creating patient mistrust, inaccurate treatment plans, coding/billing errors, and lost revenue.”

“I think, unfortunately, [medical documentation errors] are relatively common,” Dr. Bartlett said, adding, however, that “most of the time documentation errors don’t have any impact on medical care, which is good.”

In electronic health records, Dr. Bartlett said he thinks some of the most common errors occur from using a copy forward function.

“It’s easy in most medical record systems to take a previous note and duplicate it. … People will copy a note forward, and they don’t update things like new clinical findings or the plan, so you might see there is a note from several months after cataract surgery that states Mr. Jones is doing well 1 day after cataract surgery, even though he had surgery 3 months ago,” Dr. Bartlett said.

Some EHRs allow for generation of stock phrases, commonly called “dot phrases” because you use a period to invoke it, Dr. Bartlett explained.

“People have standard things. They will say we talked about the risks/benefits of surgery, patient agreed to proceed, that kind of stuff. I have seen one part of the chart say one thing and a different part of the chart say something else. For example, we had a surgeon who had a surgery where they talked with the patient about setting certain focusing with cataract surgery. The patient thought they were going to have both eyes set for near for reading. They documented that clearly in one part of the chart, but they used a stock phrase for the part of the chart that was for the plan. When they selected the lens, typically we select a lens for distance focusing, and that’s what they did, and the patient ended up with a lens focused differently than what they expected because of a documentation error.”

Coming from a paper chart perspective, Dr. Zhu said the most common error she sees is the wrong information in the wrong chart.

“I think it still applies even for clinics that are all digital because there are some things that are not completely connected to your EHR. There are a lot of scans that you have to print out and scan into the EHR. That can be uploaded into the wrong patient record. That’s the most common error that I’ve seen,” she said. “Sometimes it’s a completely different patient, and sometimes it’s because the patient shares the same name, so you always have to verify the birthday as well.”

Dr. Zhu said this has happened in her practice when technicians are printing out from devices one after another, and sometimes the whole stack of papers is scooped up and put into a chart. Sometimes, sandwiched in the middle are scans from another patient.

“I’ve educated my staff to not blindly scoop up the whole stack from the printer. They should individually look through each paper as they’re putting it into the chart, verifying the name and birthday,” she said.

Dr. Zhu and Dr. Bartlett have not experienced a negative patient outcome due to a chart error personally, though they have caught errors through safety checks before they could affect outcomes and have heard of such situations from other practices.

Dr. Bartlett said that human errors can be counteracted before and during surgery with systems of safety, including multiple checks by multiple people.

“I work with an optometrist. When we see patients, we generate our lens orders, so when we do our calculations and pick a lens for the patient, he and I do that separately, and we compare the results. If there is any discrepancy, we figure out why there is a difference so it’s very clear what they elected for and what we are selecting. Once you type it in the EHR, it looks like that’s the reality. Unless you have some other check on it, you could easily make an error,” Dr. Bartlett said.

Dr. Zhu said with ICLs, she makes sure to triple check that she’s ordering a lens with the correct axis because in the clinic, minus is used for cylinder during refractions, but the ICL needs to be converted to plus. She checks the ICL power when it is delivered to her practice before the patient is even scheduled and again on the day of surgery. It is very easy to mistakenly flip the plus/minus sign on the astigmatism, and the patient could end up with double the amount of astigmatism they started with. The same holds true for LASIK. It is important to verify that the refraction that is programmed into the laser matches the final refraction obtained on surgery day. “As a safeguard, I double check to make sure that the final refraction written in the chart is consistent with a recent refraction that was obtained at a separate preoperative visit. I then confirm once more that the numbers in the machine match the numbers in the chart with my laser surgical technician just before hitting the pedal,” she said.

While these safeguards and surgical timeouts are not built into the EHR, Dr. Bartlett said EHRs do have some safety measures. For example, if a patient has listed an allergy and a doctor tries to order a medication they’re allergic to, the system would flag it. It also flags dosages that might be considered unsafe.

From a business standpoint, medical documentation errors can be costly, not only in terms of OR resources, if a patient needs to be brought in for an additional procedure, but also in terms of insurance denials and the staff time needed to correct these issues and resubmit.

Mr. Christensen gave an example. He said the Moran Eye Center recently underwent a “Target, Probe, and Educate” audit for cataract surgery. The findings included documentation omissions: “Per LCD L37027, documentation must include an attestation supported by documented symptoms and physical findings in the medical record indicating that the patient’s impairment of visual function is believed not to be correctable with a tolerable change in glasses or contact lenses. This attestation is not present in the documentation. Also per LCD, documentation must include a statement that a reasonable expectation exists that lens surgery will significantly improve both the visual and functional status of the patient. This is not supported in documentation submitted.”

Mr. Christensen said in response to these findings, the physicians were given a standardized documentation protocol for cataract surgery to follow that would coincide with their exam findings. He also said that in partnership with University Medical Billing, a percentage of their office visits are reviewed for accuracy.

Based on the prospective review, “changes are made to bill the appropriate level of service for the work that has been documented,” he said. “Our coding team collaborates effectively with our surgeons to ensure cases are coded appropriately. In the event that a mistake is found, communication is sent to the provider for clarification and correction. Recently, a laterality error was identified in a section of an op note. The mistake was identified, the provider emailed, and an addendum created to correct the mistake prior to the release of the claim.”

Mr. Christensen said that their EHR is regularly updated, which helps facilitate accurate and timely documentation.

In general, “careful attention to the accuracy of documentation is critical to the safety/treatment of the patient and success of the business,” Mr. Christensen said.

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About the sources

John Bartlett, MD
Associate Clinical Professor of Ophthalmology
Stein Eye Institute
UCLA David Geffen School of Medicine
Los Angeles, California

Steve Christensen
Associate Director of Accounting and Finance
John A. Moran Eye Center
University of Utah
Salt Lake City, Utah

Dagny Zhu, MD
Medical Director and Partner
NVISION Eye Centers
Rowland Heights, California

Relevant disclosures

Bartlett: None
Christensen: None
Zhu: None

Contact

Bartlett: bartlett@jsei.ucla.edu
Christensen: stephen.christensen@hsc.utah.edu
Zhu: dagny.zhu@gmail.com