Ensuring Patients Receive Their Treatments: A Hospital Inpatient Perspective

Verifying that patients in the hospital are receiving the treatments and medications they need for their care is a critical responsibility for healthcare professionals. This article discusses methods to confirm treatment compliance, especially in the context of hospital inpatients.

Method 1: Checking the Medical Chart

One of the primary methods to verify treatments is by checking the patient’s medical chart. This document meticulously records all medications, treatments, and interventions provided to the patient. It serves as the official log of what was done during their hospital stay. If a treatment was charted, it was executed; conversely, if it wasn’t charted, it didn’t happen. This record-keeping practice is strictly enforced to maintain the integrity of patient care.

Why it works: Medical records are an essential part of patient care and cannot be falsified without consequences. The legal and ethical implications of altering these records discourage any such behavior.

Method 2: Engage with the Patient

Another effective approach is to directly inquire about the treatment from the patient. However, this should be done in a manner that does not alarm them. You can gently ask about their experience with the treatment.

Example: Instead of: "Have they been putting those warm compresses on every two hours the way I ordered?" Ask: "How have the warm compresses been working for you?"

If the patient is unable to provide consistent information, it is advisable to consult available family members or caregivers. Their insight can offer valuable context and confirm the patient’s treatment regimen.

Method 3: Cross-Check Departmental Records

For treatments involving multiple hospital departments, cross-checking records can provide additional validation. For instance, if a patient receives an inhalation therapy, the medical records may include a specific page dedicated to inhalation treatments, alongside records from the respiratory therapy department. Nurses’ notes can also contain references to such therapies.

Example: A nurse’s note may state: "Medication delayed—inhalation therapy in progress."

Method 4: Conduct Unannounced Visits

Timing is crucial for many treatments. Performing unannounced visits to the patient’s room can help observe the treatment being administered firsthand. Repeated unannounced visits can either confirm that the treatment is being given as scheduled or expose any irregularities in the timeline.

Why it matters: Conducting these visits multiple times can rule out occasional schedule disruptions, ensuring consistent treatment.

Method 5: Addressing Suspected Falsification of Medical Records

If there are concerns that some staff members might be falsifying medical records, this is a serious issue that requires immediate attention. Consulting with the nurse manager or the director of nursing may be necessary. They can suggest and implement strategies to investigate and address these potential issues.

Why it’s important: Ensuring the authenticity of medical records is crucial for providing high-quality care and maintaining patient safety. False documentation can lead to inadequate treatment, potentially harming the patient's health.

Case Study: Medication Non-Compliance at Home

Occasionally, patients might be non-compliant with prescribed medications, even when motivated to communicate this to their healthcare providers. For example, a patient’s blood glucose levels were well-controlled until they experienced a stroke. The patient’s wife reported that the patient had stopped taking their medications, believing there was no further need for them. This highlights the challenges of ensuring patient compliance.

Technological Advances in Compliance Monitoring

Recent advancements, such as the use of microchips in inhalers, offer innovative solutions to monitor medication usage. A study demonstrated the effectiveness of this technology. It revealed that some patients were not using their inhalers as prescribed, merely emptying them on the day of the appointment to provide empty canisters to their healthcare provider.

Why it’s important: This underscores the need for developing and adopting modern tools to enhance medication compliance and patient care.