1. Taking Medication Histories
EMTENAN ALHARBI ,Msc
Clinical Pharmacy Department

2. Learning Objectives Importance of medication history by pharmacist
State the advantages & disadvantages of interviewing patients before and after review of patient information
Identify the most relevant information from observing patient surroundings
List the categories of data to be collected during the interview
Describe the type of information under each category
Differentiate between allergy and ADR.
State how to assess patient compliance.
Identify types of questions to use and to avoid.
Discuss the different type of documentation styles

3. Medication history.. Importance
Med Hx starting point for clinician to identify the patient’s understanding of
The role of medications in the treatment of disease
Patient’s compliance
Medication’s effectiveness
Side effects, allergy

4. Why pharmacists?
Unique combination of drug related expertise and experience;
Patient trust and respect pharmacists

5. Errors attributed to incomplete Medication History
Errors of omission
Errors of commission
Incorrect dose
Incorrect frequency
Incorrect strength
Incorrect name
Incorrect dosage form

6. Medication Reconciliation
The process of comparing the patient’s preadmission medications with the medications prescribed during the hospitalization
Intended to prevent medication-related problems such as duplication, interaction..
Successful medication reconciliation depends on obtaining an accurate and complete medication history

7. What are the sources for patient information?

8. Sources of Information for patient database
Patient encounter
Patient interview: The patient is typically the primary source of medical information.
Physical assessment of the patient
Caregiver/family member
Healthcare professional caring for the patient
Medical chart

9. Steps for successful Medical History Session
Preparation
Observation of patient and his environment
Before the Interview
Data to be collected
Communication skills
During the Interview
Documentation of the Med Hx
After the Interview

10. Preparation .. Review the patient‘s information
Review patient profile then conduct the interview
Setting: hospitalized, nursing home patients
Advantage:
Prior knowledge, better preparation
More comfortable
Disadvantage:
Important information can be overlooked.
Interview patient with no background knowledge
Setting: community pharmacy
Advantage:
Unbiased
Allow for exploration of all aspects equally
Disadvantage:
Intimidating
Time consuming

11. Preparation.. Observe Patient and his Surrounding
Patient state of health
Socioeconomic status
e.g. Cost of med.
Compliance with dietary recommendations
e.g. Antihypertensive agent & salt restriction
Social support system

12. Data Collection
What type of information is included during a medication history session?
PHCL 326: communication skills for Pharmacists
4/6/2017

13. Data to be Collected Demographic Information Dietary Information
Social Habits
Current & Pat Rx medications
Current & Past OTC medication
Current & Past alternative remedies
Allergies
Adverse drug reactions
Compliance
assessment

14. Demographic Information
Age/date of birth
Gender
Height and weight
Race and ethnic origin
Residence
Education
Occupation
Life style

15. Dietary Information
Restrictions
Supplements
Stimulants
suppressants

16. Social Habits Tobacco: Alcohol: Illicit drugs
Start, quit date; quantity (pack-years)
It is quantified in terms of packs per day (ppd) and expressed in pack- tears (pk-yr)
Alcohol:
Type, quantity, pattern, duration of use
Illicit drugs

17. Social Habits..Packs-Year
Number of pack years = (number of cigarettes smoked per day x number of years smoked)/20
*1 pack=20 cigarettes
Number of pack years = (number of packs smoked per day x number of years smoked)

18. 2x5= 10 pk-yr smoking history.
Social Habits..Example
a patient who has smoked 15 cigarettes a day for 40 years has a:
A patient who smoked 2 packs per day for 5 years
(15x40)/20 = 30 pk-yr smoking history.
2x5= 10 pk-yr smoking history.

19. Current Rx medications
Name/description
Dosage
Dosing schedule (prescribed, actual, PRN)
Indications
Date med started
Outcome of therapy

20. Past Rx medications Name/description Dosage
Dosing schedule (prescribed, actual, PRN)
Indications
Date med started
Date med stopped
Reason for stopping
Outcome of therapy

21. Current & Past OTC medication
Name/description
Dosage
Dosing schedule (recommended and actual)
Indications
Date med started
Date med stopped
Outcome of therapy
Reasons for stopping the med

22. Current & Past Alternative Remedies
Name/description
Dosage
Dosing schedule (prescribed and actual)
Indications
Date remedy started or stopped
Outcome of therapy
Reasons for stopping the med

23. Allergies Name & description of causative agent Dosage
Date of reaction
Description of reaction
How the reaction was treated

24. Adverse Drug Reactions
Name & description of causative agent
Dosage
Date of reaction
Description of reaction
How the reaction was treated

25. Immunization
Vaccines
Date of administration

26. Compliance Assessment
10/07/1438
Compliance Assessment
Causes of non-compliance
ADR
Cost
Unavailability
Inappropriate dosage form
Not understanding the reason for taking the medication
Deliberate
/gab

27. Questioning Techniques
Open-ended questions
Close-ended questions
Targeted questions
Leading questions

28. Setting the stage for the interview

29. Pay attention to communication skills

30. Avoid Hindering Behaviors

31. 10/07/1438
After the Interview
Document your medication history in patient file/chart
Make sure to:
Write eligibly (print is preferred)
Record Date & Time of the interview
Your initial and signature
Write SOAP for medication related problems indentified during the interview
/gab

32. Documentation
Standardized
Freestyle
SOAP

33. 4/6/2017

34. PHCL 326: communication skills for Pharmacists
4/6/2017

35. PHCL 326: communication skills for Pharmacists
4/6/2017

36. Individual Assignment
Find a relative, neighbor or a friend and obtain a medication history from
Use the standardized data collection sheet