11 Best Possible Medication History
Outcome
Accurate and complete medication history is obtained and recorded as the first step in the medication reconciliation process, which forms the basis for therapeutic decisions to be made.
Potential Risks
Inaccurate medication histories can lead to inappropriate discontinuation/recommencement of therapy and failure to identify a medicine-related problem, potentially leading to patient harm.
EPA Template
| Element | Performance Criteria Description |
|---|---|
| Introduction to consultation | - Greet patient, establish patient identity, confirm time is convenient - Provide clear introduction to consultation, explaining your role and purpose of the consultation - Obtain patient consent to discuss patient medication history with other health professionals if necessary |
| Patient Background | - Retrieve and contextualise relevant patient factors that may impact medicines management - Consider individual patient factors: Age, gender, height, weight, pregnancy/breastfeeding status Ethnic background, social background Cognitive function and reliability as trustworthy source of information Ability to communicate in English - Review previous medical history - Consider any available pathology results or other relevant information from patient’s medical records |
| Questioning Technique | - Use an appropriate questioning technique to obtain relevant information from the patient/carer - Use appropriate person-centred language (non-judgmental and avoids medical jargon) - Use appropriate non-verbal communication skills to aid in questioning as appropriate - Consider alternative method of communication if necessary to accommodate for patients with barriers to communication (e.g. visual/hearing impairment, language proficiency, etc) - Use a mixture of open and closed questions; avoids leading and/or negative questions |
| Allergy and ADR Review | - Confirm and document accurate and comprehensive allergy and ADR history, including: Name of the medication Type of reaction Date of reaction - If patient reports no history of allergies/ADRs, ensure ‘nil known allergies’ is documented |
| Medication Details | - Uses a structured and systematic approach to obtaining a comprehensive medication history - Use multiple appropriate sources to obtain information regarding current medications, including: Patient and/or carer Patient’s own medicines list Patient’s medicines, prescriptions or Dose Administration Aid (DAA) Community pharmacy Residential Aged Care Facility (RACF) GP/specialists referral letter Electronic records (dispensing software, previous discharge medication records, etc) MyHealth record - Specifically questions patient/carer regarding the use of prescription and non-prescription medicines, including: Oral medication (e.g. tablets, capsules, liquids) Topical medication (e.g. eye/ear drops, nasal sprays, inhalers, creams/ointments, patches) Injectable medication (e.g. insulins, anticoagulants) Intermittent medications (e.g. once weekly/monthly/bi-annual bisphosphonates, once weekly methotrexate) Complementary medicines (e.g. vitamins, herbal preparations, supplements, etc) - Asks about recently changed/ceased medicines and reasons for the changes |
| Patient Understanding and Experience of Medicine Use | - Assess the patient’s understanding of their illness/condition in the context of their medicine regime - Assess the patient’s understanding of their medicines, including: Indication Perceived effectiveness and/or adverse effects Monitoring requirements - Assess the need for further information or referral - Discuss the storage of medicines at home and any issues relevant to patient adherence (e.g. swallowing difficulties, physical impairment, decline in cognition, etc) - Discuss the use of any other recreational substances including alcohol and nicotine if applicable/appropriate |
| Documentation of Medication History | - Document all relevant aspects of obtained medication history using appropriate medication history documentation tool (e.g. Medication Management Plan) - Current medicines (including non-prescription and complementary medicines): Active ingredient and brand (if relevant) Dose, form, route, frequency, indication and duration - Allergies and ADRs - Relevant recent changes to medicines - Patient’s GP and regular dispensing pharmacy - Adherence aids used |
| Confirmation of Medication History | - Confirm medication history to ensure accuracy and completeness using a second/third (if required) source of information - Clearly makes any relevant/appropriate adjustments to the documented history if needed |
