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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


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


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


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.


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.


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:


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