Dilation Declination Form

[OpticianDeb]

Does anyone know where I can find a dilation declination form or find tips on creating my own?

Thank You in advance!

[chip anderson]

I realize this is just another "fear of lawyers" tactic to protect yourself against the possiblilty of having failed to detect a condition. But is it worth the trouble. In my experience many, and I mean many ophthalmologists only dilate on the first visit on children and then only every five years or so. On older patients who may be more prone to have an internal eye problem or those with a suspicious history or ancestry, this may not be the case. But I have never heard of anyone anywhere requireing such a form. Do you really feel it's worth the trouble as it's appearently not required as the "standard of care?"

Chip

[Framebender]

and dilation is his standard of care. Right or wrong its his comfort level and I want him to provide our clients with the best possible care available. He dilates and takes fundus photos on everyone. If they refuse dilation they sign our form.

My wife and I are on vacation this week. Not going anywhere, but just hiding out. If you will email me your fax number I will fax you a copy of our refusal of dilation form. You won't get it until next week, but I will send you a copy.

You can email me at opticstogo@yahoo.com .

[EyeFitWell]

The waiver also makes the pt. clearly aware of the possible risk they're taking. I use a waiver for POF, and I explain that it's not intended to scare them, but rather just to be sure the possible outcomes were clearly communicated to each person.
I'd just write your own. "I understand that in choosing to decline being dilated, I take responsibility for any conditions that may go undetected. If a condition arises in the future which may have been detected by dilation, I will not hold Dr. ___ and his staff responsible." I think it softens the blow to explain that this is just to be sure they understand, but not to scare them into getting their eyes dilated.

At my office, we have an Optos machine which takes a retinal photo and frequently can replace the need for yearly dilations.

(By the way, what do people have against dilation anyway? It's way better than seeing the dentist!)

[scograd]

I practice in a corporate chain and most of our patients expect NOT to be dilated. (previous owners and doctors rarely dilated). We now have Optos and our patients sign a waiver before the exam indicating their choice of accepting or declining the procedure. In the event that a patient declines the Optos, I do recommend in their exam that they either have a dilated exam or the Optos so I can do a more complete eye health assesment. I still have a lot of patients (about 50%) that continue to refuse either. I document that in their chart so now I have two sets of "proof" that they declined both the optos and dilation. If I feel like there is a necessary reason to dilate, then I just tell that patient that I need to dilate, that usually goes okay. But I still worry about all those who refuse. Obviously there is some patient responsibility and I can't force them to do a procedure that they don't want done, but in today's litigious society I'd recommend doing whatever you have to to show that you tried to follow or exceed the standard of care.

[EyeFitWell]

I really don't see what is so horrible about being dilated. Of every medical procedure I can think of, it is the most non-invasive. I guess it makes you feel a little disoriented for a couple hours, but no more than a couple drinks!:cheers:

[Ory]

At my office, we have an Optos machine which takes a retinal photo and frequently can replace the need for yearly dilations.


Argh! No, No, No! The optos is not a replacement for a dilation! Any OD or MD or whatever who thinks so is deluding themselves! It tends to give a poor image vertically and has poor resolution. From first hand experience I have found many things that were not visible on an optomap image.

[fjpod]

Some may differ with me, but I don't think such dilation declination forms are necessary. If a patient refuses a "routine" dilation, simply write it in the chart.

If somebody refuses a medically necessary (urgent) dilation, record it in the chart and maybe send a notice to the PCP. Document that you warned the patient of potential consequences.

[EyeFitWell]

Argh! No, No, No! The optos is not a replacement for a dilation! Any OD or MD or whatever who thinks so is deluding themselves! It tends to give a poor image vertically and has poor resolution. From first hand experience I have found many things that were not visible on an optomap image.

Ory, read what I wrote. Can frequently replace the need for yearly dilations. It provides Doc with a more permanent record to track any changes and a wider view than he gets with the slit lamp. It is 2D, not 3D. So, sometimes he sees something on the Optos that he wants to take a closer look at. Sometimes he sees the Optos and decides not to dilate. Sometimes they've had Optos for a few years and he wants to dilate this year. I very specifically did not say it replaces dilation entirely.
:cry: So before you get all frustrated, please read carefully! Believe me, Doc has been VERY VERY CLEAR with everyone in the office about the wording and never saying anything to imply they'll never be dilated again!
:D

[rbaker]

From my understanding a statement of this nature signed by the patient isn’t worth the paper that it is printed on in a malpractice lawsuit. In fact, it could actually work against a practitioner by establishing his routine level of care. An appropriate notation in the patients chart, such as “patient denies dilation” is about the best you can do.

EyeFitWell said “At my office, we have an Optos machine which takes a retinal photo and frequently can replace the need for yearly dilations.” – Do you routinely dilate everyone annually?

EyeFitWell said “I really don't see what is so horrible about being dilated. Of every medical procedure I can think of, it is the most non-invasive. I guess it makes you feel a little disoriented for a couple hours, but no more than a couple drinks!’ What about that minority of patients with extremely shallow angles. I recently had an optometric eye exam and observed that immediately after registering, all eye exam patients were administered drops and dilated.

In addition, the standard of care in that practice is to perform retinal imaging and automated perimetry on an annual basis. While we can all agree that comprehensive and timely procedures are in the patients best interest, this level of care is arguably a case of overkill and perhaps motivated by the practitioners pecuniary interests rather than patient welfare.

Dilation is a valuable tool, to be used wisely and judiciously. If you practice wisely and judiciously you should not have too much concern for these issues of juris prudence.

[Ory]

Ory, read what I wrote. Can frequently replace the need for yearly dilations. It provides Doc with a more permanent record to track any changes and a wider view than he gets with the slit lamp. It is 2D, not 3D. So, sometimes he sees something on the Optos that he wants to take a closer look at. Sometimes he sees the Optos and decides not to dilate. Sometimes they've had Optos for a few years and he wants to dilate this year. I very specifically did not say it replaces dilation entirely.
:cry: So before you get all frustrated, please read carefully! Believe me, Doc has been VERY VERY CLEAR with everyone in the office about the wording and never saying anything to imply they'll never be dilated again!
:D

I am very tired of hearing people talk about how great the Optomap is. I constantly hear that it replaces a dilation, and the Optos people like to perpetuate that idea. Patients do get that idea regardless of what you tell them. "I paid extra for a picture and the doctor didn't put in those nasty burning drops that make my vision blurry"

From first hand experience, there are a few things that the Optomap is good for. It impresses the patient. It allows an alternative to dilation for the docs who wouldn't dilate anyway. And of course, it is a source of revenue. I've just found that anything I've seen on an Optomap photo would be easy to see with the slit lamp/BIO, while I have seen many things with the slit lamp that were not visible on the Optomap due to poor resolution.

As to your original comment, perhaps a better phrasing may be: and can defer the need for a dilation to the following year. :cheers:

Not trying to thread-jump here; back to the original topic. When a patient refuses to be dilated I check that off on the form and write a reason. If I am strongly in favour of dilation I will ask them to sign the exam form next to the dilation declined box and explain again why I'm insisting on it. I've never had someone actually sign yet.On the other hand, we in Canada aren't quite so worried about being sued!

[chip anderson]

Seems to me I can remember a doc or two mentioning that dilation can cause a latent glaucoma pt. to become acute. One reason some M.D.'s gave in opposing it's being available to O.D.'s and lay people.
As to what's so bad from the "normal" patient's point of view, if he has sat in the doctor's office for hours before getting seen, then goes to his office to try to catch up on all the work. He allowed one hour for this and probably shot four down, and now he finds he can't see a damn thing of his paper work until the dillation wears off.
Mysteriously, some people object to this and put off thier next visit to the eye doctor for years.

Just a thought or two.

Chip

[Ory]

Seems to me I can remember a doc or two mentioning that dilation can cause a latent glaucoma pt. to become acute. One reason some M.D.'s gave in opposing it's being available to O.D.'s and lay people.

If I was at risk for an angle closure glaucoma attack, I'd sure rather have it in my eye doctor's office rather than when I'm in a dark theatre watching a movie.:cool:



As to what's so bad from the "normal" patient's point of view, if he has sat in the doctor's office for hours before getting seen, then goes to his office to try to catch up on all the work. He allowed one hour for this and probably shot four down, and now he finds he can't see a damn thing of his paper work until the dillation wears off.


Yeah. I have a real issue with doctors who always make you wait on them. If I can always count on waiting a full hour before being seen, why should I show up on time? As for the near blur, that is a side effect I could live without but I'd rather have that once every 2 years than have an undiagnosed disease. But that's just me....:hammer:

[Dave Nelson]

Mydriasis can, as Chip points out, precipitate an angle closure episode, although such occurances are extemely rare. Regarding the use of non-mydriatic fundus photography and the lack of resolution, why is there such a difference in from the new digital X-rays in common usage now. I would think that the resolution for these would have to be extremely high in order to replace the traditional film. Why doesn't this hold true for fundus photos?

[orangezero]

Mydriasis can, as Chip points out, precipitate an angle closure episode, although such occurances are extemely rare. Regarding the use of non-mydriatic fundus photography and the lack of resolution, why is there such a difference in from the new digital X-rays in common usage now. I would think that the resolution for these would have to be extremely high in order to replace the traditional film. Why doesn't this hold true for fundus photos?

The optomap does have some advantages that are mentioned above. However, its abilities lie in getting a "decent to fair" view of a great range of the fundus. Nothing is too detailed. With other fundus cameras, there is much less retinal area per picture, but the resolution is greatly enhanced.. So, its ok for finding things, poor for documentation, or for monitoring (IMO). I dont' care much for the company that makes it because of their poor financing dealings and how it has to be a lease. There are studies here or there, or someone will talk at a CE about how optomap really does detect better than dilation, but guess who's paying for those studies?

I don't know if they have some type of patent on the optics part of it, but I'm at least a little surprised there hasn't been competition.

hope that makes sense..

[fjpod]

I think Optos is a nice tool. It doesn't replace anything. I just think their leasing scheme is rediculously expensive (and unethical, IMHO).

[npdr]

1. A patient can never "sign" away their right to a "tort". That means there is no informed consent form that can absolve a doctor from being liable. Informed consent is exactly that, it is a piece of paper that informs the patient of something

2. I've dilated probably 5,000 patients a year and have yet to be alarmed at the precipitation of an acute angle closure attack.

3. Whether the Optomap or dilated fundus exam is either sufficient is something that will spawn discussion for yiears to come. In the field of diabetic retinopathy, studies have shown that the combination of dilated fundus exam with an ophthalmoscope and retinal imaging is far superior than either separately. If doctors are so bound to having the best, why not do both?

[nickrock]

Is anyone billing 92004 or 92014 withOUT dilation?

[fjpod]

Is anyone billing 92004 or 92014 withOUT dilation?
It's theoretically possible if you are managing a complex case where dilation is not urgent, or contra-indicated, but other care is provided. But, for the most part, dilation would be included, especially on the 92004.

[f2chow]

I flat out refuse to see patients, mainly seniors, who refuse dilation. It's as simple as having my license on the line. If someone isn't willing to allow you to perform an exam to your standards, then is it really worth the sale to take on a patient who "thinks" they know the health status of their eyes better than you? It only takes 1 lawsuit to undo all the good you've think you've done by accomodating someone who doesn't like the drops.
The worst offenders are the ones that see general OMDs and refuse dilation because the other doc dilated. Again, would you put your complete trust in hoping that the OMD caught everything? If I would have trusted every patient who claimed their OMD did everything and only wanted a refraction then I'd be knee deep in lawsuits from the patients where I found tears, choriodal melanomas, visually significant cataracts (yes ... it was presumed to be keratoconus ... but wasn't). I'm not faulting OMDs, quite the opposite. I certainly don't expect an OMD to not perform a dilated exam on someone whom I've referred out for cataracts .... who knows, I probably didn't miss anything but heck if they would blindly trust me .. I also wouldn't trust another OD clinic as well! When you see the patient last you become the "doctor of record" and then you'll have to own up to why you didn't do a simple procedure that would have caught the problem ... and somehow I don't think the answer of "I thought the other doc did it" would be too convincing.

Sorry for the vent ... just had this happen today, again, and it's got me all fired up (thank God it only happens about once or twice a year)!

[Dave Nelson]

You can vent all you want... doesn't change the fact people can decline any medical procdure they want to. If they are advised of the reason for the procedure, then decline it, you can have them sign the waiver, or just make a note on their file that they declined the procedure against your professional advice. Its called informed consent.

[FVCCHRIS]

As an Optician, and not a Dr., this is what I think: I don't think it would ever matter one bit what you had a patient read, sign, agree to bla-bla-bla... If you ever end up in court for anything like this the only question their attorney will ask you is-- Why did you lower your level of care for this patient???? I think no matter what, the judge and jury are going to look unfavorably on that point. As far as treatment is considered, YOU'RE the expert, not the PATIENT..If I were a Dr., and I felt dilations were an important part of my examination I would politely decline to see patients that felt inconvenienced by it. jmho...Chris..

P.S. Remember when you were a kid in trouble and you told your Mom-"they made me do it"?? Imagine telling a jury that? he-he-he

[f2chow]

Thank you Chris! It's good to see I'm not the only one who thinks this way!

While Dave is right that the person has the right
to decline any procedure they want, we also have a right to rufuse accepting them as patients. Again, it goes to practicing to the
highest level of care possible. Why anyone would expose themselves to potentially missing a serious problem is beyond me. And remember Dave, these are primarily people 65+ I'm complaining about. Even in BC where opticians are trying to refract there are stipulations against stand-alone refractions for people past a certain age and with certain medical conditions. What's any different when I get the same person and end up only refracting, doing a slit lamp examination and trying to look through a 70 year old's 1.5mm pupils and cataracts? Why send theese people out of your optical when they're going to get the same level of care in a doctor's office? My family is all in the optical business, with an aunt in BC as a optician who refracts. I'm very much pro- opticians refracting so don't think I'm just here to be a PITA. It's not uncommon for any doc to discharge patients to failure to comply with treatment .... why should we as professionals in the optical industry lower our standards then? The question will always be "could you have caught it IF you did dilate?".