Medication history taking

1. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
MEDICATION HISTORY
TAKING
SOPH 312
EMMANUEL SARKODIE FPCPharm
2/27/2024 MEMBER OF AMERICAN COLLEGE OF CLINICAL PHARMACISTS
(ACCP)

2. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
OBJECTIVES
Define medication reconciliation and describe the role of
the medication history in the medication reconciliation
process.
Identify relevant information obtained from observing
the patient’s appearance and environment.
List the categories of data obtained during a medication
history interview
Discuss the advantages and disadvantages of
documenting the patient medication history using a
standardized form, the SOAP format, and the freestyle
format
2/27/2024

3. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
INTRODUCTION
Medication history is the foundation for planning optimal
patient-specific medication regimens.
The medication history is the starting point for generating
hypotheses regarding:
 The patient’s understanding of the role of medications in
the treatment of disease
 The patient’s ability to comply with the medication
regimen
The medication’s effectiveness
The patient’s experiences with side effects, allergies, and
adverse drug reactions.
2/27/2024

4. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
INTRODUCTION
Although other health care professionals interview
patients regarding their use of medications.
 No other health care professional has the pharmacist’s
depth and scope of knowledge regarding medications.
Since Pharmacists have a unique combination of drug-
related expertise and experience with patients trust and
respect.
Hence it is important that pharmacists obtain and
document patient medication histories and communicate
this information to the rest of the health care team.
2/27/2024

5. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
Incomplete or incorrect admission medication histories may
put the patient at risk due to:
Interrupted therapy
Unnecessary therapy
Duplicative therapy
Incorrect therapy (inappropriately low or high dosages).
For hospitalized patients, the medication
history is the first step in the medication
reconciliation process.
2/27/2024

6. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
What is a Best Possible Medication
History (BPMH)?

7. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
What is a BPMH?
An accurate and complete medication history, or as
close as possible
Uses at least one other source of medicines
information to verify
More comprehensive than a routine primary
medication history

8. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
Contents of a BPMH
Includes prescription, non-prescription and
complementary medicines
Details the following:
- Medication name, strength, dose, route and frequency
- How long the patient has been taking the medications
- Patient’s understanding of indication for use
- Any recently ceased or changed medications
- Any allergies or adverse drug reactions

9. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
Why Take a BPMH?
10-67% of medication histories contain at least one error
Incomplete medication histories at the time of admission
have been cited as the cause of at least 27% of prescribing
errors in hospital
The most common error is the omission of a regularly
used medicine
Around half of the medication errors that happen in
hospital occur on admission or discharge
30% of these errors have the potential to cause harm

10. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
Why Take a BPMH?
A complete and accurate medication history is needed to
establish a basis for decisions about medication
management while in hospital.
These statistics clearly support the need to for an
accurate medication history to be taken and documented
as early as possible in the episode of care.
2/27/2024

11. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
Obtaining a BPMH
Collect a medication history
- Patient/carer interview when possible AND/OR
- Other sources of medicines information e.g. community
healthcare provider
Confirm the obtained information
- Use a secondary source to verify the information OR
- Use two or more sources of information to obtain and verify
the medication history
These two steps may occur in succession or concurrently

12. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
Whenever possible a patient/carer interview should
occur, when this is not possible other sources of
medicines information can be used.
Use as many sources as required and practical to feel
confident that a medication history is complete and
accurate.
A minimum of two sources should be used to collect
and confirm a medication history.
2/27/2024

13. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
Sources of Medicines Information
Sources may include:
- Patient/carer interview (wherever possible)
- GP medication list, referral letter, phone call
- Patient medication list
- Community pharmacy dispensing history
- Residential Aged Care Facility (RACF) medication chart
- Patient’s own medications, prescriptions or dose administration
aids
- Previous hospital discharge summary
- HealtheNet Portal (via eMR) which can access information from
My Health Record

14. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
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

15. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
If patient can not remember a medication or if clarification
is needed:
- Get a description of the medication from the patient or
family member (form, strength, size, shape, color,
markings)
- Contact family member that could possibly bring in the
medication or read it over the phone
- Call the patient’s pharmacy
- Contact the specialist’s office or other physician to get an
accurate list of medications
- Obtain previous medical records
2/27/2024

16. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
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

17. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
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)

18. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
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?

19. UNIVERSITY OF HEALTH
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School of Pharmacy
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

20. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
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)

21. UNIVERSITY OF HEALTH
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School of Pharmacy
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)

22. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
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

23. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
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?

24. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
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?

25. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
Structured, Systematic Process for
Interview
1. Review relevant patient information
2. Introduce yourself and explain the purpose of the interview
3. Ask about previous adverse drug events or allergies
4. Ask about prescription, non-prescription and complementary
medicines
5. Use a checklist
6. Assess patient’s understanding, attitude and adherence
7. Organise and document medicines information

26. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
1. Review Patient Information
• Types of information that may be useful:
- Age, gender, ethnic background/religion, social history
- Ability to communicate, cognition, alertness
- Previous medical history
- Laboratory results or other findings
- Presenting condition
- Working diagnosis
• Identifies issues to focus during the interview
• Aids in prioritisation of patients if required

27. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
Background information about the patient’s health and social status
can assist in establishing the existence of, or potential for,
medication-related problems.
Age - Younger and older patients are at most risk of medication-
related problems. A patient’s age will indicate their likely ability to
metabolise and excrete medications, which has implications for
appropriate selection of drug and dosage
Social background - This may impact on the patient’s ability to
manage their medicines and influences their medication care needs
e.g. live alone
Previous medical history - Concurrent medical conditions may guide
the selection of appropriate therapy, help identify drug-disease
contraindications and identify untreated conditions
2/27/2024

28. UNIVERSITY OF HEALTH
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School of Pharmacy
Laboratory and other findings (if available) - Renal function,
liver function, full blood count, electrolytes, blood pressure,
cardiac rhythm, therapeutic drug monitoring and pain scores -
may identify over or under treatment or the need to adjust
therapy
Presenting condition - Could their symptoms be adverse
effects related to their prescription or non-prescription
medicines?
Or could lack of symptom control indicate poor adherence,
inadequate dose or inappropriate drug choice?
Establishing this background information will allow you to
identify issues to focus on during the interview, provide insight
into the types of medications the patient may be taking and
will assist in assessing the appropriateness of therapy
2/27/2024

29. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
2. Introduction
• Provide clear introduction
• Explain purpose of interview
• Respect patient’s right to decline interview
• Determine person responsible for administration and
management of medicines
• Obtain patient consent before requesting information
from other healthcare providers or carer

30. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
3. Previous Allergies or Adverse Drug
Events
• Document previous allergies or adverse drug events
- On the National Inpatient Medication Chart (NIMC)
- In the patient’s medical record according to hospital
policy
• Document specifically:
- Drug
- Type of reaction
- Date of reaction

31. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
4. Prescription, Non-Prescription and
Complementary Medications
• Obtain specific details of all medications
- Name, strength, dose, route, frequency, duration and
perceived indication
- Any recently started, ceased or changed medications
Hints
• Treat each medication separately i.e. obtain all
information before moving onto the next medication
• Document as you go
• Do not rely on memory!

32. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
4. Prescription, Non-Prescription and
Complementary Medications
• Begin with open-ended questions
- What medicines do you take?
- What medicines do you take when you need?
- Do you take any medicines for pain/to help with
sleep/heartburn?
• Ask about medications for specific conditions identified from the
medical history
- What medicines do you take for you diabetes/high blood
pressure?
• End with specific prompts
- How often do you take your pain medicine?
- Do you take that in the morning or at night?

33. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
The clinician should guide the interview to obtain the
necessary information by tailoring the questions and
discussion:
• Questions must be relevant and succinct
• Appropriate language must be used, e.g. non judgemental,
use terminology that the patient will understand.
Appropriate questioning makes it easier to obtain relevant
information from the patient, e.g. begin the medication
history with open-ended questions to encourage the patient
to explain and elaborate, then move to close-ended questions
to systematically minimise omissions and to confirm details.
The clinician must talk at a level which enables the patient to
hear, but does not compromise patient confidentiality.
2/27/2024

34. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
5. Use a Checklist
• To avoid omitting relevant details use a written or mental
checklist
• Each patient’s perception of what a medicine is will vary
• Ask about:
- Injectable medicines
- Once weekly or intermittent medicines
- Topical medicines e.g. eye drops, creams, patches
- Puffers, sprays or inhalations
- When needed medications for pain/sleep/constipation etc.
- Oral contraceptives, hormone replacement
- Social and recreational drugs

35. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
Use of a structured process/checklist will improve the
accuracy and completeness of the medication history.
Whenever possible the checklist should be used as it
reduces the likelihood of omitting relevant details.
It prompts the patient’s memory of medications that they
did not bring with them.
2/27/2024

36. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
6. Assess Patient’s Understanding, Attitude
and Adherence
• Elicit patient’s understanding of:
- Their illness
- Indication of each medicine
- Perceived effectiveness
- Perceived problems attributable to medicines
- Current monitoring of disease/medicine
• Assess adherence by asking:
- People often have difficulty taking their medicines for one reason
or another...Have you had any difficulty taking your medicines?
- How often would you say you miss taking your
medicines?

37. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
Gauging the patient’s understanding of their illness allows you to elicit what
the patient perceives their health care needs to be.
This may impact on how the patient deals with health professionals and the
way they use medications.
A poor understanding of their illness may need to be addressed before the
patient can fully understand what treatment is necessary and the rationale
for treatment.
Their understanding can be elicited by seeking information on their:
• Understanding of rationale for treatment
• Perception of the purpose of the medicines and their effectiveness
• Perception of potential adverse effects
• Understanding of monitoring of disease/medicine
• These perceptions may impact on the patient’s adherence to prescribed
treatment.
To obtain honest, open responses regarding a patient’s adherence choose
questions which are non-judgemental and normalise non-adherence.
2/27/2024

38. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
7. Organise and Document Medicines
Information
• Document the BPMH according to hospital policy
- Front of the National Inpatient Medication Chart (NIMC)
- Dedicated form e.g. NSW Medication Management Plan (MMP)
- In the electronic medical record
• Ensure availability at point of care e.g. with the current NIMC
• Ensure the following details are clearly documented:
- Patient details
- Date (and time) of documentation
- Name and contact details of clinician completing history
- List of medicines (name, strength, dose, route, frequency, duration and indication)
- Source/s of information
- Information about previous adverse drug events or allergies
- Recently started, ceased or changed medications

39. UNIVERSITY OF HEALTH
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It is important that the medication history is documented
in a way that allows it to be readily accessed by all members
of the health care team.
Suitable areas include the front of the National Inpatient
Medication Chart (NIMC),
The NSW Medication Management Plan (MMP) or similar
form and in the electronic medical record.
As long as they are available at the point of care.
The information gathered during the patient/carer
interview, as listed, should be documented clearly and
succinctly.
This includes the other sources of information used to
verify the information obtained during the interview.
2/27/2024

40. UNIVERSITY OF HEALTH
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School of Pharmacy
Use the BPMH to Reduce Adverse Events on
Admission
• Prescribers should use the BPMH when determining
the medications to be prescribed for the patient on
admission
- Considering each medicine in the BPMH, the patient and
the presenting condition
- Determining and documenting the plan for each medicine
e.g. to continue, change dosage or frequency, withhold or
cease

41. UNIVERSITY OF HEALTH
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School of Pharmacy
All decisions about medication management ideally should be
based on a complete and accurate record of a patient’s pre-
admission medications.
As the BPMH represents the most complete and accurate
record as possible, prescribers should use it to determine the
medications to be prescribed for the patient on admission.
This involves considering each medicine, the patient and the
presenting condition followed by determining and documenting
the plan for each medicine e.g. to continue, change dosage or
frequency, withhold or cease.
The BPMH is not always available to prescribers at the time of
admission.
 In this situation the admitting condition should be treated and
processes should be put in place which allow the BPMH to be
obtained as soon as possible after admission.
2/27/2024

42. UNIVERSITY OF HEALTH
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How to overcome pitfalls...
Consider:
is it complete
is it current
is it what the patient is actually taking?
Avoid relying on one source of information

43. UNIVERSITY OF HEALTH
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School of Pharmacy
Conclusion
• A BPMH is vital for ensuring continuity of care:
- Helps reduce the risk of medication errors
- Has patient safety and organisational benefits
• A dedicated form (e.g. MMP) may facilitate the process of
documenting a BPMH
• Be aware of the limitations with sources of medicines
information

44. UNIVERSITY OF HEALTH
AND ALLIED SCIENCES
School of Pharmacy
REFERENCES
• SHPA Standards of Practice for Clinical Pharmacy
• Clinical Skills for Pharmacists, A Patient-Focused
Approach (Tietze, J, ed 3)
• Pharmacy Practice Experiences – A Students Handbook
(Setlak, P)
• Hospital Pharmacy (Stephens, M ed 2)
• Medication Review: A Process Guide for Pharmacists
(Chen, T et al, ed 2)
2/27/2024