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Basic History

Medication History

On this page:Medication History


  • The patient's medication history is a very important aspect of their medical history. Documenting a comprehensive list of a patient's medications allows for correct charting of medications as well of the identification of potential drug interactions or adverse effects.
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    • Any medications the patient is on
    • What pharmacy they get their medications from
    • Whether they use any dosing aids, such as a Webster pack
    • Sources of Medication Lists

    • It is often best to derive your list from at least two sources, especially when there is doubt.
    • The patient - sometimes patients present with a useful list of their medications
    • Collateral - from family or friends
    • Medication boxes - often patients present with their medications; ask if there are any missing
    • The patient's file - especially discharge summaries
    • Other hospitals - especially discharge summaries or transfer letters
    • The patient's GP
    • The patient's pharmacy

Medication History

    • Prescription

    • Form - e.g. tablets, capsules, eye drops, nasal spray or injections
    • Administration - e.g. oral, IM or IV
    • Dose - the strength of the medication and how much they take eg how many tablets
    • Frequency - how often they take the medication
    • Indication

    • Why the patient is taking the medication. This is often evident but sometimes not. Often the patient does not know themselves!
    • Prescriber

    • Who prescribed the medication initially, and who continues to prescribe it.
    • Timing

    • When they were started on the medication
    • If they are not on the medication indefinitely, how long they will take it for and whether they are on a weaning dose regimen.
    • Side Effects

    • Whether the medication is associated with any unwanted side effects.
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