3 Grading
Jeffrey D. Perotti, M.S., O.D.
For each patient encounter, fill out an encounter record in Meditrek immediately if possible, and no later than the end of the day. The following describes my overall grading approach.
“A” Level – indicates that you performed at a level higher than expected, and usually occurs when you identify and manage a new, relatively complex issue during your patient encounter or perform extremely well on a patient with known multiple complex issues. It can also include a complex refraction. Documentation is appropriate, as is choice of tests during the examination.
“B” Level – indicates that you performed as expected, and will generally include few to no written comments. There was minimal to no change in the refraction, and no new medical or ocular issues were discovered. Documentation is appropriate, as is choice of tests during the examination.
“C” Level or Lower – indicates performance below the level of expectation. You shouldn’t worry much about earning one or two of these scores; however, repeated scores in this range generally indicate an area or areas that need work. You are required to talk to your clinical instructor if you receive a “C” Level or lower score.
Be aware that our expectations advance as the year advances. The table below attempts to provide additional insight into the information above.
| Grade Level | Description | Insurance Review | Eyeglass Prescription | Ocular Diagnoses | Systemic Diagnoses | Assessment and Plan, Coding | Time |
|---|---|---|---|---|---|---|---|
| "A" level | Above expected level for the encounter | Insurance is reviewed prior to start of encounter and appropriate Compulink layout AND chief complaint is used for the encounter based patient insurance | An appropriate Rx history and Rx - including add - is determined during the encounter. Rx is deemed to be more complex than a usual Rx. | New non-refractive ocular diagnoses are appropriately documented and managed, changes to existing treatment plans for existing non-refractive ocular diagnoses are appropriately inititated. | New systemic diagnoses are appropriately documented and managed, changes to treatment plans for existing systemic diagnoses are appropriately inititated. | Appropriate procedural (CPT) and diagnostic (ICD-10) codes are provided in an appropriate order based on chief complaint and/or insurance; A&P is justified by chart and follows evidence-based clinical care. No issues in any of the items. | Less than allotted |
| "B" level | As expected level for the encounter | Insurance is reviewed prior to start of encounter and appropriate Compulink layout OR chief complaint is used for the encounter | An appropriate Rx history and Rx - including add - is determined during the encounter. Rx is either not changed from habitual, or requires minimal changes from habitual. | No new non-refractive ocular diagnoses, no changes in existing non-refractive diagnoses, or simple ocular diagnoses such as pinguecula | No new systemic diagnoses, no changes in existing systemic diagnoses, or simple systemic diagnoses such as hypertension are appropriately documented and managed | Appropriate procedural (CPT) and diagnostic (ICD-10) codes are provided in an appropriate order based on chief complaint and/or insurance; A&P is justified by chart and follows evidence-based clinical care. One to two issues with the items above. | As allotted |
| "C" level or below | Below expected level for the encounter | Appropriate Compulink layout and chief complaint is NOT used for the encounter | Rx history and Rx - including add - is inappropriate or inaccurate. | New non-refractive ocular diagnoses are not appropriately documented and managed, or changes to existing treatment plans for existing non-refractive ocular diagnoses are not appropriate. | New systemic ocular diagnoses are not appropriately documented and managed, changes to existing treatment plans for existing systemic diagnoses are not appropriate. | Appropriate procedural (CPT) and diagnostic (ICD-10) codes are provided in an appropriate order based on chief complaint and/or insurance; A&P is justified by chart and follows evidence-based clinical care. More than two issues with the items above. | More than allotted |