Definition of Medication History
Medication history is the detailed, accurate, and complete information of all the prescribed and non-prescribed medications that a patient has taken or currently taking in a hospital, ambulatory, or OP care.
It identifies patient’s needs and helps to improve the efficiency of medication by rendering medication errors and concerns of illness and treatment.
It provides valuable information about patients’ allergies and adherence to pharmacological and non-pharmacological treatments. It serves as a starting point for other clinical activities like DIs, ADR, Medication counseling, etc.
Goals:
- To optimize patients’ drug therapy.
- To appraise the drug administration techniques.
- To prevent or minimize drug-related problems and medication errors.
- To screen for potential drug Interaction
- Assess for the evidence of drug abuse.
- To prevent potential mortality and morbidity.
Steps Followed by Medication History
Interviewing The Patient:
This is mainly done to gather information about the patient, identifying the potential problems that he is facing, the disease, and its duration. These are:
- Demography details of the patient.
- Family history of the patient for any hereditary diseases and allergies.
- Immunization status.
- Regular habits like smoking, alcoholism, and diet variations.
- Previous consultations and treatment plans, duration of the therapy.
- Reasons for discontinuation or alteration of medications.
- Storage conditions of the medications if required.
- Adherence to past treatment courses and use of adherence aids.
Components To Be Documented:
Research has established that in routine practice pharmacists provide the most accurate information when compared to other health care professionals. They are submitted to physicians for further evaluation. Components are
- Current consultation.
- OTC Medications, vaccinations, and duration of therapy.
- Alternative or Traditional remedies.
- Patient-specific considerations like Pregnancy, disease status, and allergies.
- Record of drug, dose, dosage schedule, dosage form, route of administration with respect to age, renal function, and liver functions.
- Medication intolerance or hypersensitivity.
- Review of medication records for cost-effectiveness.
Follow Up:
- Identify and resolve drug-related problems.
- Refill information, Missed doses
- Lifestyle modifications.
- Encourage patients for further assistance.
Patient medication history Form:
Medication History Interview
Introduction
Patient Medication history interviews help the pharmacist establish rapport with the patient, commence preliminary counseling, and help devise an ongoing pharmaceutical care plan
Sources: Patient, medication records from the hospital, and other sources.
Goals:
- To gather information to be utilized in case discussion
- Compare medication profiles with the medication administration record and investigate discrepancies
- Verify medication histories taken by other staff and provide additional information where appropriate
- Document allergies and adverse reactions
- Screen for drug interactions to assess patient medication compliance
- Assess the rationale for drugs prescribed
- Assess for evidence of drug abuse
- Appraise drug administration techniques
- Examine the need for medication aids
- Document patient-initiated medication administration
Documentation
- Documentation of medication history includes
- Current medication administration record
- Previous prescriptions
- Current admission details
- Referral letter from local doctor or other sources
- The patient’s own medication list.
Preparing for the Interview
- Determine specific goals of the interview
- Establish the identity of the patient
- Introduce yourself
- Explain the purpose of the interview
- Respect the patient’s right to decline an interview
- Adopt a suitable physical position to enable the interview to take place comfortably and effectively.
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