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J. A. Qureshi, P. P. Lee, P. Mruthyunjaya, S. Bearelly, I. J. Suner; Documentation of Initial Evaluation for Diabetic Retinopathy Among Ophthalmologists: Comparison to the AAO Summary Benchmarks. Invest. Ophthalmol. Vis. Sci. 2007;48(13):2398.
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© ARVO (1962-2015); The Authors (2016-present)
To evaluate documentation of initial diabetic eye evaluations (history, physical examination, diagnosis, and patient education) for the presence of Key Elements as defined in the AAO’s Summary Benchmarks for Preferred Practice Patterns.
A retrospective chart review was carried out using 80 charts from 12 physician practices. Among the patients evaluated from 1/1/01 to 7/31/03 who were diagnosed with diabetes mellitus, diabetic retinopathy, and/or macular edema, charts from each center were selected for review using a random, stratified sample (to obtain charts without retinopathy, with retinopathy, and with macular edema). The charts were reviewed for documentation of the Key Elements of the initial evaluation history, physical exam, diagnosis, and patient education as defined in the AAO’s Summary Benchmarks. The presence or absence of each of the Key Elements was recorded. The average number of Key Elements documented was recorded.
On average, one of the four (24%) Key Elements of the history portion of the evaluation were documented (range of 0 to 3). On average, 5.6 of the six (93%) Key Elements of the initial physical exam were documented (range of 3 to 6). The diagnosis of diabetic retinopathy, or lack thereof, was documented in 78% of the charts; the severity of the disease was documented in 65% of reviewed charts. The presence or absence of CSME was documented in 41.5% of the reviewed charts. Less than 10% of reviewed charts documented even one of the 7 Key Elements of patient education.
Documentation of the Key Elements of the history, diagnosis, presence or absence of CSME, and patient education during initial diabetic examination can be improved significantly. Further understanding the impact of levels of conformance to patient outcomes will be important for future inquiry.
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