TAKING MEDICATION HISTORIES

EMTENAN ALHARBI ,Msc

Clinical Pharmacy Department

Learning Objectives

1. Importance of medication

history by pharmacist

2. State the advantages &

disadvantages of interviewing

patients before and after

review of patient information

3. Identify the most relevant

information from observing

patient surroundings

4. List the categories of data to

be collected during the

interview

5. Describe the type of

information under each

category

6. Differentiate between

allergy and ADR.

7. State how to assess patient

compliance.

8. Identify types of questions

to use and to avoid.

9. Discuss the different type of

documentation styles

2

Medication history.. Importance

Why pharmacists?

Errors attributed to incomplete Medication

History5

Errors of omission Errors of commission Incorrect dose Incorrect frequency Incorrect strength Incorrect name Incorrect dosage form

Medication Reconciliation

The process of comparing the patient’s preadmission medications with the medications prescribed during the hospitalization Intended to prevent medication-related

problems such as duplication, interaction.. Successful medication reconciliation

depends on obtaining an accurate and complete medication history

What are the sources for patient information?

7

Sources of Information for patient database

8

Patient encounter

Patient interview: The patient is typically the

primary source of medical information.

Physical assessment of the patient

Caregiver/family member

Healthcare professional caring for the

patient

Medical chart

Steps for successful Medical History Session

9

Preparation .. Review the patient‘s information

Review patient profile then conduct the interview

Setting: hospitalized, nursing home patients

Advantage: Prior knowledge,

better preparation More comfortable

Disadvantage: Important information

can be overlooked.

Review patient profile then conduct the interview

Setting: hospitalized, nursing home patients

Advantage: Prior knowledge,

better preparation More comfortable

Disadvantage: Important information

can be overlooked.

Interview patient with no background knowledge

Setting: community pharmacy

Advantage: Unbiased Allow for exploration

of all aspects equally Disadvantage:

Intimidating Time consuming

Interview patient with no background knowledge

Setting: community pharmacy

Advantage: Unbiased Allow for exploration

of all aspects equally Disadvantage:

Intimidating Time consuming

10

Preparation.. Observe Patient and his Surrounding

11

Patient state of health

Socioeconomic status

e.g. Cost of med.

Compliance with dietary

recommendations

e.g. Antihypertensive agent & salt restriction

Social support system

What type of information is included during a medication history session?

Data Collection

04/11/23

12

PHCL 326: communication skills for Pharmacists

Data to be Collected13

Demographic Information Age/date of birth Gender Height and weight Race and ethnic origin Residence Education Occupation Life style

Dietary Information15

Restrictions

Supplements

Stimulants

suppressants

Social Habits16

Tobacco:

Start, quit date; quantity (pack-years)

It is quantified in terms of packs per day (ppd) and

expressed in pack-tears (pk-yr)

Alcohol:

Type, quantity, pattern, duration of use

Illicit drugs

Social Habits..Packs-Year17

Number of pack years = (number of

cigarettes smoked per day x number of

years smoked)/20

*1 pack=20 cigarettes

Number of pack years = (number of packs

smoked per day x number of years smoked)

Social Habits..Example18

a patient who has smoked 15 cigarettes a day for 40 years has a:

A patient who smoked 2 packs per day for 5 years

(15x40/)20 = 30 pk-yr smoking history .

2x5= 10 pk-yr smoking history .

Current Rx medications19

Name/description

Dosage

Dosing schedule (prescribed, actual, PRN)

Indications

Date med started

Outcome of therapy

Past Rx medications

Name/description

Dosage

Dosing schedule (prescribed, actual, PRN)

Indications

Date med started

Date med stopped

Reason for stopping

Outcome of therapy

Current & Past OTC medication

21

Name/description

Dosage

Dosing schedule (recommended and actual)

Indications

Date med started

Date med stopped

Outcome of therapy

Reasons for stopping the med

Current & Past Alternative Remedies

22

Name/description

Dosage

Dosing schedule (prescribed and actual)

Indications

Date remedy started or stopped

Outcome of therapy

Reasons for stopping the med

Allergies23

Name & description of causative agent

Dosage

Date of reaction

Description of reaction

How the reaction was treated

Adverse Drug Reactions24

Name & description of causative agent

Dosage

Date of reaction

Description of reaction

How the reaction was treated

Immunization

Vaccines Date of administration

Compliance Assessment26

Causes of non-compliance ADR Cost Unavailability Inappropriate dosage form Not understanding the reason for taking

the medication Deliberate

Questioning Techniques27

Open-ended questions

Close-ended questions

Targeted questions

Leading questions

Setting the stage for the interview

28

Pay attention to communication skills

29

Avoid Hindering Behaviors30

After the Interview31

Document your medication history in patient file/chart Make sure to:

Write eligibly (print is preferred) Record Date & Time of the interviewYour initial and signature

Write SOAP for medication related problems indentified during the interview

Documentation32

Standardized Freestyle SOAP

Individual Assignment 36

Find a relative, neighbor or a friend and obtain a medication history from

Use the standardized data collection sheet