Patient Medication History

Patient Medication History

1. Patient Medication
History Interview

2. Medication History Interview

° A medication history is a detailed, accurate and complete
account of all prescribed and non-prescribed medications
that a patient had taken or is currently taking prior to a
initially institutionalized or ambulatory care.

It provides valuable insights in to patient’s allergic
tendencies, adherence to pharmacological and non-
pharmacological treatments and self medication with
complementary and alternative medicines.

Interviewing a patient in collecting the data medical

history is called medication history interview.

3. Need of Medication History Interview

e Preventing prescription errors and consequent risk to
patients.

+ Useful in detecting drug —related pathology or changes in
clinical signs that may be the result of drug therapy.

° It should encompass all currently and recently prescribed
drugs, previous adverse drug reactions including herbal
or alternative medicines and adherence to therapy for

better care plan.

4. Need of Medication History Interview

The following information is commonly recorded:
1. Currently or recently prescribed medicines

2. OTC medication

3. Vaccinations

4. Alternative or traditional remedies

5. Description of reactions and allergies to medicine
6. Medicines found to be ineffective

7. Adherence to past treatment and use of adherence aids

5. Patient Information Sources

1. Patient

2. Family or caregiver

3. Medication vials / packets
4. Medication list

5. Community pharmacy

6. Patient Interview

+ Introduce yourself

+ Inform patient of reason for you being there

e Inform patient of importance of maintaining a current

medication list in chart

7. Patient Medication History Interview Questions

° Which community pharmacy do you use?
+ Any allergies to medications and what was the reaction?
° Which medications are you currently taking:
Q The name of the medication
The dosage form
The amount (specifically the dose)
How are they taking it (by which route)
How many times a day
Any specific times

For what reason (if not known or obvious)

8. Patient Medication History Interview Questions

e What prescription medications are you taking on a

regular or as needed basis?

e What over-the-counter (non-prescription) medications are

you taking on a regular or as needed basis?

e What herbal or natural medicines are you taking on a

regular or as needed basis?

+ What vitamins or other supplements are you taking?

9. Other Questions

Have you recently started any new medications?

Did a doctor change the dose or stop any of your medications
recently?

Did you change the dose or stopped any of your medications
recently?

Are any of the medications causing side effects?

Have you changed the dose or stopped any medications
because of unwanted effects?

Do you sometimes stop taking your medicine whenever you
feel better?

Do you sometimes stop taking your medicine if it makes you

feel worse?

10. Medication History Interview Tips

Have Balance open-ended questions (what, how, why,
when) with yes/no questions

Ask non-biased questions

Explore vague responses (non-compliance)

Avoid medical jargon — Keep it simple

Avoid judgmental comments

11. Medication History Interview Tips

a

Cards for Medication History Script à

MEDICATION HISTORY SCRIPT

Allergies

+ Do you have an allergy to or avoid any
medications due to side effects?

+ What type of reaction de you have?

Prescription Medications

+ What preseription medications do you take
on a regular basis?

» When de you take them?

Non-prescription Medications

= What non-prescription over-the-counter
medications do you take on a regular basis?

+ When do you take them?

Herbals, Supplements, Vitamins
+ What herbal, natural or homeopathic remedies
do you take?
What vitamins on minerals do you take?
When do you take them?

ADDITIONAL QUESTIONS

Do you use any:
Eye drops
Nose sprays
Puffers (inhalers)
Medicated lotions on creams
Medicated patches

Do you receive any:
+ Needles (injections)
+ Samples from the doctor's office
+ Study medications

Do you take any medication on a regular basis
for:

- Sleep

+ Your stomach

+ Your bowels

+ Pain

Did you or your doctor recently change or stop
any of your

12. Medication History Interview Form

Medication History Inte:
form
Demographie Data :

Male/Female:
[ Ward
‘Admission Date Interview Date

1 PRESCRIBED MEDICATION:-(What medicines are you having at the moment?

A)Record here what the patient says, not anomalies with their current prescription,

Pp Man pea NT EET Tai

13. Medication History Interview Form

2.NON PRESCRIBED MEDICATION:-Do you take anything that you buy from a shop without a

prescription-chemist, health food stores, super market?
A)Currently being used:

B)Used previously(with dates if possible):

E)Alcohs
Ermici Drugs:

4.Respon

IF yes, how

¡no why?

ifno, why?

14. Medication History Interview Form

5.Do any of the things you buy without a prescription, helped you?
If yes, how and which ones?

6.SIDE EFFECT:

A)Are you suffering any side effects now? If yes, what side effects.

B)Which of your medicines do you think is causing the problems?

7.COMPLIANCE:

A)How do you remember to take your medication?

B)What do you do when you miss a dose?

15. Medication History Interview Form

|8. What medicines would you usually take for
A) Headache:

B) Aches/Pains and Flu:

[C) Allergy

|9. Who would you ask for medicines for Headache, Allergy, Flu etc
A) Pharmacist/Chemist:

B) Relative or Friend:

C) Nurse

D) Doctor:

\E) No-one:
T

16. Medication History Interview Form

Medication History interview Form

10, Any other problems with Drug Therapy’?

Signature of Pharmacist