Provocative title, I know, but it may be time for a gross reality check. I was in need of one; and boy, was I glad for the experience; I think the question has heightened my awareness to the integral role that honesty has in our profession. The following is not meant to be punitive, derogatory or malicious, but rather the musings of a fallible provider of humanitarian aid.
As critical care providers we are subject to a lot of chatter; a lot of “the speak”.
Often, this comes in short bursts of catchy or easy to remember phrases. For example, “Our day begins when yours is about to end.” or “You gotta be sick to fly with us.” One that struck a particularly curious tone within me went something like this –
“Data out is only as good as the data going in.”
I must confess I’ve never really been a huge fan of numbers, statistics, calculations, etc., but throughout my academic and clinical experience, I have come to acknowledge and embrace its role in our profession. You’re probably thinking, how on earth does the collection of data interface with being a truthful and honest provider? Allow me to share…
Many of the current, electronic patient care documentation platforms available are nothing more than aggregates for collecting, mining, sourcing and analyzing pools of data. This data is then compiled and reported in a variety of charts, graphs, tables and publications; specifically targeting a proposed change or clinical issue based on a known trend – as derived from the data.
This is great! We now have a bunch of nicely colored information, perfectly displayed and ready for all to feast upon. We tear into this information, sinking our teeth into the disparities, the trends, THE KNOWLEDGE. But wait; is there a catch to all this greatness?
All of those colorful and organized reports are a direct reflection of what the clinical provider has entered, at the very beginning when the patient care record was generated – the very genesis of said data.
I’ll come right out and say it:
If the clinical provider has fudged his or her documentation and entered it into the record – that’s the same data that will be reviewed by the powers that be – on the other end.
And it is on that “other end” where weighty decisions are made; decisions like protocol development, medical guideline changes, clinical practice augmentations, etc.
I have been a provider for about ten years now and have been witness to this very phenomenon, but its impact never really moved me past the fact of frank untruthfulness. Putting aside the ethical deviation for a moment, let’s focus on the effect it has on the evolution of “evidence based practice”. Let’s stage a case scenario – the patient is complaining of 6/10 pain.
According to our medical guidelines this is considered moderate pain and we can administer 15 mgs of IV Ketorolac. However, during the administration process the provider “actually” gives 30 mgs, a dose that is outside of protocol, but is safe and justified according the clinician’s medical judgment. Miraculously the patient tolerates it really well and is pain free on arrival to the hospital. Its decision time – do we chart 15 mgs and let the chart pass the QA process, demonstrating that we “followed” protocol? Or do we chart that we gave 30 mgs and risk having our clinical judgment and medical justification questioned? Perhaps you yourself have experienced, witnessed or even done this – or maybe not. I can assure you that this exists in practice, and I don’t think it is exclusive to critical care or EMS…
Let’s say that the above scenario happens once a day, every day for one month. At the end of the month, we run a report and find that WOW – 6/10 pain is treated really well with 15 mgs of IV Ketorolac – therefore, there is no need to alter the guideline…because our protocol / guideline seems to be effective…! But is it really?
Whether you are charting the number of IV attempts, or the dose of an administered medication, I would urge that all providers visit their inner sanctum for a moment; and ask themselves, am I a truly, truthful provider? It makes a way bigger deal than we may think!!
EMS and critical care providers are some of the best people on the planet – they will do almost anything for anyone at anytime – I don’t think any of us deliberately would ever do something to harm a patient, family member or fellow provider – let’s make sure that we are daily, and actively engaging integrity as routine in our clinical practice!!
Until the next time…Be well and stay safe.
This article was not written in response to a known or growing concern, but merely intended as a timely reminder – stressing the importance of truthfulness in patient care documentation and understanding its impact on data collection and analysis.
Bruce Hoffman is a critical care nurse, paramedic and current graduate student. He works as both a clinician and educator in Connecticut, Massachusetts and Maryland, with background in the division of critical care (ICU, ER, Cardiology, and Flight). He enjoys professional gigs in clinical and distance medical education, advocacy, leadership, consultation and blogging. He is a frequent and national lecturer for a host of Emergency Medical Services and Critical Care continuing education programs. He remains a member of his hometown ambulance service where he has served in a variety of administrative and operational roles. In his spare time, Bruce enjoys spending time with his wife Stephanie as well as traveling, hiking and biking.