8 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

 

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School of Pharmacy Preceptor Handbook Copyright © 2023 by The University of Queensland is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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