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Basic History
 
 
Basic History
Good clinical history-taking is the first important step in diagnosis. The history can be used to understand the patient's presenting issue, as well as the biological, psychological and social context that forms the background of the presenting issue.
Vaccination History
 

Medication History

 
 

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

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.
Last updated on October 6th, 2017
 
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