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How good are we at documenting cataract surgery electronically?

Poster Details

First Author: S.Sim UK

Co Author(s):    B. Paul                    

Abstract Details

Purpose:

To determine the quality of documentation of cataract surgery on Medisoft�Â�© an electronic records system within BHR hospitals

Setting:

Department of Ophthalmology, Barking, Havering and Redbridge University Hospitals, United Kingdom

Methods:

Cataract surgeries performed within BHR Hospitals between 1st October 2015 and 30th September 2016 were included in the audit. The actual number of surgeries performed was determined from operating theatres�â�€�™ logbooks. The number of surgeries documented on Medisoft�Â�©, completeness and accuracy of PCR risk stratification and ocular co-morbidities within the electronic pathway were determined using Medisoft�Â�© audit tool. A departmental survey was conducted to identify barriers to good quality documentation.

Results:

A total of 1657 cataract surgeries were performed during the time period of audit. 655 surgeries (39.5%) were entered on Medisoft�Â�©. Of those entered, 2 surgeries (0.3%) had fully completed PCR risk stratification tab, 267 (40.8%) had partially completed tab and in 386 (58.9%), the PCR tab was not completed. Only 40% of ocular co-morbidities were accurately entered on the system. A departmental survey identified several barriers to poor documentation including lack of awareness, time constraint, and computer technical issues.

Conclusions:

The quality of electronic cataract care records within BHR hospitals is suboptimal. This needs to be addressed urgently as this data contributes to the RCOphth National Ophthalmology Database.

Financial Disclosure:

NONE

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