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Med History


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Med History

  1. 1. Conducting a Medication History
  2. 2. What’s the Point?? <ul><li>To be an effective provider: </li></ul><ul><ul><li>Perform/Obtain necessary assessments of the patient’s health status </li></ul></ul><ul><li>Medication History can: </li></ul><ul><ul><li>Determine medical conditions </li></ul></ul><ul><ul><li>Family History </li></ul></ul><ul><ul><li>Social History </li></ul></ul><ul><ul><li>Etc. </li></ul></ul>
  3. 3. Health Literacy <ul><li>Level of understanding of disease state or medication </li></ul><ul><li>Patient may not know how to express details otherwise </li></ul><ul><li>Be sure to keep this information handy, as it may be useful later </li></ul>
  4. 4. Developing a Relationship
  5. 5. Create Safe Environment <ul><li>Patient feels more comfortable communicating </li></ul><ul><li>Greet the patient with a smile </li></ul><ul><li>Make eye contact </li></ul><ul><li>Introduce yourself and verify the patient’s identity </li></ul><ul><li>Emphasize your role as a caregiver </li></ul><ul><li>Encourage complete, truthful report of information </li></ul>
  6. 6. Ask the Right Questions <ul><li>Use a combination of open-ended and closed-ended questions </li></ul><ul><li>Combine this with active listening </li></ul><ul><li>Open-ended </li></ul><ul><ul><li>Encourages patient to expand on information </li></ul></ul><ul><li>Closed-ended </li></ul><ul><ul><li>Reserved for confirming details and guiding discussion </li></ul></ul>
  7. 7. Active Listening <ul><li>Interpret information to confirm, clarify or encourage discussion </li></ul><ul><li>Techniques: </li></ul><ul><ul><li>Interpretation: “You have been asking a lot of questions…is there something worrying you? </li></ul></ul><ul><ul><li>Reflection: “You said ___. Tell me more about that” </li></ul></ul><ul><ul><li>Clarification: “I don’t understand completely. Tell me what you mean by ___” </li></ul></ul><ul><ul><li>Empathy: “That must have been frustrating for you…” </li></ul></ul><ul><ul><li>Facilitation: “I’m listening…” </li></ul></ul><ul><ul><li>Confrontation: “You appear to be…more than what you’re saying” </li></ul></ul>
  8. 8. Watch Non-Verbals <ul><li>Eye Contact </li></ul><ul><ul><li>Make or break a relationship </li></ul></ul><ul><ul><li>Shows either caring, or lack of interest </li></ul></ul><ul><li>Patient Cues </li></ul><ul><ul><li>Fidgeting, closed body position could indicate discomfort </li></ul></ul><ul><ul><li>Acknowledge, be empathic – could help alleviate </li></ul></ul>
  9. 9. Cultural Competence <ul><li>Ability to address patients with diverse values, beliefs and behaviors </li></ul><ul><li>Tailor delivery to meet patient’s social, cultural and linguistic needs </li></ul><ul><li>Examine your own culture and beliefs… </li></ul><ul><li>Think about mainstream health care model… </li></ul><ul><li>Differences? </li></ul>
  10. 10. Note Taking <ul><li>Address early as a helpful tool </li></ul><ul><li>Not judgmental </li></ul><ul><li>Provides accuracy with record keeping </li></ul>
  11. 11. Patient Knowledge <ul><li>Gather information regarding </li></ul><ul><ul><li>Preferences </li></ul></ul><ul><ul><li>Attitudes </li></ul></ul><ul><ul><li>Understanding </li></ul></ul><ul><ul><li>Concerns </li></ul></ul><ul><ul><li>Expectations </li></ul></ul><ul><ul><li>Adherence </li></ul></ul><ul><li>Can help you to tailor interventions to the patient </li></ul>
  12. 12. To Review… <ul><li>Introduce yourself – establish a relationship </li></ul><ul><li>Be open and attentive to patient reports </li></ul><ul><li>Collect pertinent information about medications </li></ul><ul><ul><li>Names, doses, frequencies, believed indications </li></ul></ul><ul><li>Open-ended questioning </li></ul><ul><li>Collect a complete picture of the patient </li></ul>