Provocative title, I know, but it may be time for a gross reality check. I know I was ready for one and, boy, was I glad for the experience.
This 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’ve never really been a huge fan of numbers, statistics, calculations, etc., but throughout my academic and clinical experience, I’ve come to acknowledge and embrace this concept’s important role in our profession.
But, how on earth does the collection of data interface with being a truthful and honest provider?
Bad Data In = Bad Data Out
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, analyzing the trends, gathering the knowledge.
But there’s a catch to all this greatness.
All of those colorful and organized reports are a direct reflection of what the clinical provider entered at the very beginning of the process when the patient care record was generated.
If the clinical provider “fudged” his or her documentation and entered it into the record, we get a similar type of “fudged” result on the other end of the process. Because that’s the same data that will be reviewed by the powers that be.
And it’s on the other end of the process where weighty decisions are made — decisions like protocol development, medical guideline changes, clinical practice augmentations, etc.
Charting the Evidence
I’ve been a provider for about ten years now and have witnessed 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 impact 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 at the hospital.
It’s 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 actually 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’s 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. There’s no need to alter the guideline because our protocol seems to be effective. Right?
But Is it Really Right?
Whether you’re charting the number of IV attempts, or the dose of an administered medication, I would urge all providers to visit their inner sanctum for a moment and ask themselves: Am I a truly truthful clinician How good is the data you’re putting in? It has a much greater impact than we may think.
EMS and critical care providers are some of the best people on the planet. They’ll do almost anything for anyone at any time. I don’t think any of us would ever deliberately to harm a patient, family member or fellow provider. Let’s make sure that we’re actively engaging integrity as routine in our daily clinical practice.
Author’s note: This article wasn’t written in response to a known or growing concern, but merely intended as a timely reminder about the importance of truthfulness and accuracy in patient care documentation and understanding its impact.