Eyeworld

38 | EYEWORLD | DECEMBER 2023 ATARACT C LESSONS LEARNED by Liz Hillman Editorial Co-Director 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 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 upload- ed 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 experi- enced 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 discrepan- cy, 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. D espite best efforts, medical docu- mentation 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 satisfac- tion. 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 docu- mentation 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" be- cause 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 Learning from medical documentation errors continued on page 40

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