By Leah A. Grebner, PhD, RHIA, CCS, FAHIMA
Today’s health care delivery system requires patients to be actively involved and well-informed when communicating with health care providers. Unfortunately, this doesn’t work well for all patients and situations. Patients often plan ahead with advance directives for health care decision-making, but it is also a great idea to plan ahead to have a companion lined up to go along to appointments, or even the hospital, if you find yourself in a condition in which you do not feel 100 percent.
When in the hospital, patients have many distractions and are often unable to fully focus on things due to health conditions or pain. For this reason, it may be helpful to have a family member or a close, trusted friend present during important communications with health care providers. Even patients who have a higher level of knowledge about health care may not be able to thoroughly process information and instructions from health care providers. Health care providers often make the assumption that patients who are health care professionals don’t need to have information and instructions communicated at a lower level, but perhaps the health care professional who is a patient is not as well-versed in the specialty for which they are being treated, or they may be overwhelmed upon receiving a critical diagnosis.
Occasionally, a patient may not have any family in the area or may not have any friends with whom they are comfortable sharing their personal health information. A recent trend followed by some patients in this type of situation is the use of a medical note taker. These individuals generally are independent consultants, or even serve as volunteers to provide the service. The medical note taker attends physician office visits and may even be used in the hospital setting to be present when the physicians make daily rounds.
Be alert to health care provider communications that are apart from the discussions directly with you or your loved one. It is common practice now for nursing staff to do a shift change report in the patient rooms, rather than in a group meeting in a conference room. If you are in the room when this happens, listen carefully, as you may pick up information not previously shared, or you may even be able to identify incorrect information that is communicated. If you do hear something incorrect, speak up. No matter how insignificant something may seem, there is always a possibility that the incorrect information could potentially impact treatment of one of the present conditions.
In the long-term care setting, patients and family members should be aware of the state long-term care ombudsman program. The ombudsman program has been in existence since 1972 for the purpose of advocating for the patient’s rights in the long-term care setting, responding to complaints related to long-term care, and addressing quality issues. Some of the issues that the ombudsman address include elder abuse, elder justice, guardianship, infection prevention, licensing and certification, misuse of psychotropic medications, staffing shortage, and threat of early discharge or transfer.
No matter what type of health care setting in which you or your loved one is receiving health care services, it is important that you:
• Know your rights as a patient and exercise them.
• Ask questions if you feel you need further clarification or explanation about information given to you by your provider. Don’t settle for simple responses if you feel the need for greater detail or more information.
• Prepare a list of questions prior to your appointment, write them down, and take the list to the appointment with you.
• Take detailed notes while the provider is giving information so that you can review and research additional information after your appointment.
• Contact your provider if you come up with questions after you leave your appointment.
• Do not be afraid to speak up and question any information that you feel may not be accurate.
Advocating for yourself and your family is one of the best ways to protect yourself and ensure that you are able to receive the highest quality of care across the continuum of health care. By doing so, it could save the expense of repeat or unnecessary testing, time of gaps in communication, or even your life from incorrect communication.
For information about how patient advocacy, call Leah Grebner, PhD, RHIA, CCS, FAHIMA, director of the Health Information Technology department at 309-692-4092. Looking to change your career? Visit www.midstate.edu or call 309-692-4092. Midstate College is located at 411 West Northmoor Road, Peoria, IL, 61614.
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