Overview
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
Overview
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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