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Basic History

Medication History

February 15th, 2021
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.
  • Ask About

  • 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


  • 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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