Accurate Medical Records Could Reduce Incidence of Poor Ophthalmology Follow-up

OphthalmologyFailure to follow up is a serious concern and could lead to grave consequences for patients. Physicians rely on accurate medical records to provide the necessary treatments for their patients, and for reliable medical documentation most physicians utilize medical transcription services. Medical transcription is a vital step in creating a patient’s medical history, which acts as a reference for physicians and lays the foundation for future patient visits. Just like other medical specialists, ophthalmologists also require accurate medical records for patients who have medical and surgical eye problems.

Ophthalmologists are primarily concerned with correcting imperfections and treating various conditions of the eyes. They diagnose abnormalities and perform eye surgeries such as cataract extraction, lens replacement, cornea reshaping and many other procedures. During a patient encounter, ophthalmologists document important details including patient history, medicines prescribed, lab reports etc. A detailed medical report of the patient makes it easy for them to communicate with the patients and chart out a suitable treatment plan.

Patients at Risk Due to Poor Ophthalmology Follow-ups

In 2009, the UK National Patient Safety Agency (NPSA) reported that 44 people with glaucoma experienced some harm due to poor follow-up appointments. From July 2007 to November 2012, sixteen patients suffered from serious incidents as they did not return for recommended follow-up visits at the Moorfields Eye Hospital in London. In response to NPSA’s concern, Moorfields analyzed the medical reports of patients who failed to follow up over 5 years. They identified 145, 234 episodes as lost to follow up and most were from ophthalmology and other related services like optometry etc. They found that the highest risk cases were glaucoma and retinal cases that made up 3.6 and 10.7 percent respectively. The investigators found 79,562 of the cases were for patients who had died. They determined that 15,153 required clinical review and made appointments for 12,316; 1146 cases were accident and emergency patients, and a sample of 50 showed no clinical harm.

OphthalmologyReasons for Poor Follow-ups

  • In 79,562 cases (54.8%), incomplete administrative processes to discharge the patients constituted the reason why the patients did not return for follow-up.
  • 18,098 (12.5%) resulted from patients not showing up for appointments they had scheduled.
  • 47,574 (32.8%) resulted from appointments that were cancelled – cancellations were made by patients in some cases and by hospital administrators in others.

The investigators found that 16 patients faced serious problems due to failure to follow up. 14 patients had glaucoma, one with a central vein occlusion and secondary glaucoma following a dexamethasone intravitreal implant. Another patient had a benign pleomorphic adenoma of the orbit. Almost all patients suffered significant visual field loss due to failure to follow up.

New Processes Initiated to Minimize the Issue

After reviewing literature, Moorfields initiated new processes to minimize poor follow-up which includes written policies and training for administrative support to emphasize there must be an outcome for each patient at the end of clinic. They have a log for patients for whom there are no outcomes, a senior clinician to review the notes of the patients who do not attend appointments or cancel appointments. The hospital has also taken steps to increase awareness via governance, business, and teaching meetings of the risks involved in failing to follow-up.

Medical records played an important part in revealing the above discussed statistics, which highlights the need for accuracy and timeliness in medical documentation. Outsourcing medical transcription to a transcription service provider has proven beneficial to ophthalmologists and other medical practitioners when it comes to maintaining reliable medical records. Accurate medical records also help physicians evaluate the current physical condition of the patient and identify a suitable treatment plan. A detailed patient record enhances communication among ophthalmology specialists, and also enables quick and correct follow-up measures.

Julie Clements

About Julie Clements

Joined the MOS team in March of 2008. Julie Clements has background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort. Julie was instrumental in the creation of the medical record review division (and new web site); and has especially grown this division along with data conversion of all kinds.