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Medication history

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Medication history

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Medication history

  1. 1. Obtaining THE BEST POSSIBLE MEDICATION HISTORY Medication Reconciliation Initiative Winnipeg Regional Health Authority
  2. 2. OUTLINE  Information Sources  Challenges with difficult clients  Questions to Ask  Tips for Performing Medication History  Client Education  Tools  Reconciliation and documentation
  3. 3. Information Sources  Patient  Family or Caregiver  Medication Vials / Bubblepacks  Medication List  Community Pharmacy  Medication Profile from other facility  DPIN (Drug Programs Information Network)
  4. 4. CHALLENGES with Difficult clients  Belief – physician has information  Unfamiliar with medications and names  Difficulty recalling  Medicated clients (sedated, confused)  Disease affects mental status  Language barrier  Hearing impairment  Elderly clients  Caregiver administers or sets up medications  Medication vials or list unavailable
  5. 5. Interviewing the client  Introduce yourself  Inform client of reason for you being there  Inform client of importance of maintaining a current medication list in chart
  6. 6. QUESTIONS to ASK  Which community pharmacy do you use?  Any allergies to medications and what was the reaction?  Which medications are you currently taking: • 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)
  7. 7. QUESTIONS to ASK  What prescription medications are you taking on a regular or as needed basis?  What over-the-counter (non-prescription) medications are you taking on a regular or as needed basis?  What herbal or natural medicines are you taking on a regular or as needed basis?  What vitamins or other supplements are you taking?
  8. 8. Medication History Taking TIPS  Balance open-ended questions (what, how, why, when) with yes/no questions  Ask non-biased questions  Avoid leading questions  Explore vague responses (non-compliance)  Avoid medical jargon – Keep it simple  Avoid judgmental comments
  9. 9. Medication History Taking TIPS  Various approaches can be used: • 24 hours survey (morning, lunch, supper, bedtime) • Review of Systems (head to toe review) • Link to prescribers (family physician, specialists)
  10. 10. Medication History Taking TIPS  Prompt for: • Pain medications • Stomach medications • Medications for bowels • Sleeping aids • Samples  Prompt for: • Eye or ear drops, nose sprays • Patches, creams & ointments • Inhalers (puffers) • Injections (needles)
  11. 11. Medication History Taking TIPS  If medication vials available: • Review each medication vials with patient • Confirm content of bottle • Confirm instructions on prescription vials are current  If medication list available: • Review each medication with patient • Confirm that it is current  If bubble packs available: • Review each medication with patient • Confirm patient is taking entire contents
  12. 12. 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?
  13. 13. Additional Questions to Explore Effectiveness/Compliance  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?
  14. 14. Cards for Medication History Script
  15. 15. Client Education  Encourage ownership  Educate client to bring medications from home at each appointment  Educate client to carry a list of current medications (prescription and OTC)  Encourage family members/ caregivers to become involved  Encourage one pharmacy
  16. 16. Client Information brochure
  17. 17. Provincial Tool for clients – creating a list  ISTA Medication card • “It’s Safe to Ask” medication card developed by the Manitoba Institute of Patient Safety • Available: • Free of charge on www.safetoask.ca • From Local Senior Resource Councils • From Fire Paramedic Stations • From participating pharmacies • From participating physicians and primary care providers
  18. 18. Other Tools available  R & D “ Knowledge is the best medicine” • Available free of charge • www.canadapharma.org  Site developed medication cards or printed sheets  Piece of paper, notebook ** Assist when required **
  19. 19. Reconciliation and Documentation  Upon discovering a discrepancy • Update the list if minor (eg OTC taken as needed) • Include medications prescribed by other physicians (eg specialist) • Inform physician if client is not taking as prescribed  Document in the client’s chart • The date MedRec completed and initial on the medication reconciliation status record • Any pertinent information in the progress notes
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