Delegating the Pressure Check
ClearView Eyecare employs a medical assistant with no optometry license. The office protocol says the assistant may perform noncontact tonometry, pachymetry, and visual fields before the optometrist sees the patient. On a busy Saturday, the assistant obtains a pressure of 31 mmHg in the right eye of a 64-year-old patient, tells him “you probably have glaucoma,” and schedules a follow-up in six months without notifying Dr. Patel, who is seeing three other patients. The assistant also instills a dilating drop because the chart says “dilated fundus exam.” Dr. Patel later signs the chart without reviewing the pressure or the assistant’s note. The patient has a family history of angle-closure glaucoma and takes an anticholinergic medication. Two days later he presents to an emergency department with eye pain and blurred vision.
1. Which tasks may an unlicensed assistant perform, and what level of supervision is required in Pennsylvania?
Read the worked answer
Unlicensed assistants may perform administrative tasks and certain preliminary tests under the direct supervision of a licensed optometrist, but they may not diagnose, interpret results, or counsel a patient about a disease. The exact list is set by Board regulation and the office’s written protocol. Noncontact tonometry and visual fields can be delegated only if the optometrist is on site, available, and reviews the results before the patient leaves; the assistant cannot decide that a pressure of 31 is “probably glaucoma” or set a six-month follow-up. Instilling a dilating drop is a clinical act that should occur only under a protocol that specifies authorization, contraindications, and documentation. The assistant’s statement and scheduling decision exceeded any permissible preliminary role.
2. Identify the standard-of-care and professionalism failures in this scenario.
Read the worked answer
The core failure is that an abnormal, sight-threatening finding was never reviewed by the optometrist. Dr. Patel signed the chart without reading the pressure or note, which is not meaningful supervision and breaches the standard of care. The assistant practiced beyond scope by interpreting the result and giving a diagnosis. The office failed to ask about the family history of angle-closure glaucoma and the anticholinergic medication before dilation, and it failed to provide same-day referral for a markedly elevated pressure with narrow-angle risk. The record likely lacks a supervisory note, a risk assessment, and patient education. These are both standard-of-care and unprofessional-conduct issues because they show indifference to patient safety.
3. What must Dr. Patel do now, and what changes should the practice make?
Read the worked answer
Dr. Patel should contact the patient immediately, arrange urgent ophthalmologic evaluation, document the contact and the reason for referral, and ensure the emergency department records are obtained. He should not backdate or rewrite the chart; he should add a dated addendum. The practice should revise written protocols to require optometrist review of every abnormal test before the patient leaves, prohibit assistants from interpreting results, and require documentation of supervision. Staff need training on angle-closure risk and dilation contraindications. If patient harm occurred, Dr. Patel should notify his carrier and consider whether self-reporting to the Board is required. The practice should also audit a sample of charts to see whether the same shortcut affected other patients.