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Medication History Interview

The medication history interview is used to obtain an accurate account of all prescribed and non-prescribed medications a patient is taking. This information is important to prevent errors, detect potential issues, and inform care plans. The goals are to collect details on drug use history, allergies, adherence, and effectiveness to compare to medical records and verify with other sources. Common questions focus on current and past medications, doses, reasons for use, adherence, side effects, and pharmacy information.

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1K views3 pages

Medication History Interview

The medication history interview is used to obtain an accurate account of all prescribed and non-prescribed medications a patient is taking. This information is important to prevent errors, detect potential issues, and inform care plans. The goals are to collect details on drug use history, allergies, adherence, and effectiveness to compare to medical records and verify with other sources. Common questions focus on current and past medications, doses, reasons for use, adherence, side effects, and pharmacy information.

Uploaded by

Pooja agarwal
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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MEDICATION HISTORY INTERVIEW

 A medication history is a detailed , accurate and complete account of all prescribed


and non-prescribed medications that a patient had taken or is currently taking prior to
a initially institutionalized or ambulatory care .
 It provides valuable insights in to patient’s allergic tendencies, adherence to
pharmacological and non-pharmacological treatments and self-medication with
complementary and alternative medicines .
 Interviewing a patient in collecting the data medical history is called medication
history interview.
Importance of accurate drug history
1. Preventing prescription errors and consequent risk to patients.
2. Useful in detecting drug –related pathology or changes in clinical signs that may be
the result of drug therapy.
3. It should encompass all currently and recently prescribed drugs, previous adverse
drug reactions including herbal or alternative medicines and adherence to therapy for
better care plan.
Goals
 The goal of medication history interview is to obtain information on aspects of drug
use that may assist in overall care of patient .
 The information collected can be utilized to :
1. Compare medication profile with the medication administration record and
investigate the discrepancies .
2. Verify medication history taken by other staffs and provide additional information
where appropriate.
The following information is commonly recorded:
1. Currently or recently prescribed medicines
2. OTC medication
3. Vaccinations
4. Alternative or traditional remedies
5. Description of reactions and allergies to medicine
6. Medicines found to be ineffective
7. Adherence to past treatment and the use of adherence aids
Information sources
1. Patient
2. Family or caregiver
3. Medication vials / bubble packs
4. Medication list
5. Community pharmacy
6. DPIN (Drug programs information network)
Question to Ask
1. Which community pharmacy do you use?
2. Any allergies to medications and what was the reaction ?
3. Which medications are you currently taking:
4. The name of the medication
5. The dosage form
6. The amount (specifically the dose)
7. How are the taking it(by which route)
8. How many times a day
9. For what reason
10. What prescription medications are you taking on a regular basis or as needed basis?
11. What over the counter medications are you taking on a regular or as needed basis?
12. What herbal or natural medicines are you taking on a regular or as needed basis?
13. What vitamins or other supplement are you taking?
14. Have you recently started any new medicines?
15. Did a doctor change the dose or stop any of your medications recently?
16. Did you change the dose or stopped any of your medications recently?
17. Are any of the medications causing side effects
18. Have you change the dose or stopped any medications because of unwanted effects ?
19. Do you sometimes stop taking your medicine whenever you feel better?
20. Do you stop taking your medicine if it makes you feel worse?

10 steps to take an accurate inpatient medication history

Step 1: Introduce yourself to patients and ask for permission to discuss their home
medications.
Step 2: Check each patient’s name and date of birth.
Step 3: Ask whether they came to the hospital from their home or a facility, if you are
uncertain.
Step 4: Ask whether they manage their own medications or if someone helps them.
Step 5: Ask about the name, strength, dose, route and frequency of their medications.
Step 6: Ask about OTC products, vitamins and any medications taken less often.
Step 7: Ask about inhalers, injectables, creams/ointments, eye drops, ear drops, nasal sprays,
patches and medication samples.
Step 8: Ask which pharmacy/pharmacies they use and inquire about allergies.
Step 9: Thank them and ask whether they have any questions.
Step 10: Evaluate the medication history obtained against at least one additional source.

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