Treatment of a disease or injury is a core function of medical care. A patient’s health condition and their choices of treatment will have significant impacts on their daily life, their relationships with family and friends and their work. A person’s ability to understand their medical condition and treatment options is also a key factor in making treatment decisions.
A medical treatment is any act or procedure carried out to improve, maintain or restore a patient’s health. It may include diagnostic procedures, surgery and other non-surgical interventions such as injections or the use of medication. Treatments are provided in physician offices, clinics and other locations such as hospitals, home visits or schools. They may involve medications, tests or other treatments and are often provided by a physician, nurse, physician assistant or medical student.
When a medical treatment is provided, the doctor and the patient must both agree on what is being done and why. This is based on a proper understanding of the risks and benefits of the treatment, and the doctor’s professional judgment. This includes weighing the benefits against the risks of not taking action, and considering the patient’s preferences. Patients have the right to receive complete and accurate information about their condition, treatment options, risks and potential side effects. The doctor must clearly explain the benefits and risks, including a possible alternative course of action, and answer any questions or concerns the patient might have.
The doctor must discuss with the patient a plan of action, and the medical treatment must be documented in a medical record. The document, called a chart note or a visit record, should contain the chief complaint (CC), which are the symptoms the patient is experiencing in their own words. It should also list the patient’s current activity, occupation and hobbies, and their family history of illness.
In some cases, a patient’s doctor may send them to a specialist for further evaluation. The specialist will review the CC and test results and then advise on a treatment plan. The specialist should explain their recommendations to the patient, and if they are unclear about them, the patient should ask for more information or a written copy of the specialist’s notes.
Medications and other treatments that don’t cure the disease, but are meant to increase a patient’s comfort, are considered supportive treatment. For example, resting, drinking fluids, and taking over-the-counter pain relievers can help a patient feel more comfortable while they recover from an illness.
Sometimes a person will not have the mental capacity to make medical treatment decisions. This can be due to an illness such as dementia, severe burns, or a coma. The doctor will talk to the patient about what types of treatments they would like to have if they were unable to speak for themselves, and ask the patient’s surrogate or the holder of their healthcare power of attorney to help them with these decisions. This process is known as advance directives.