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Obtaining THE BEST POSSIBLE MEDICATION HISTORY

Published byBarbara Lamb Modified over 9 years ago

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Presentation on theme: "Obtaining THE BEST POSSIBLE MEDICATION HISTORY"— Presentation transcript:

1 Obtaining THE BEST POSSIBLE MEDICATION HISTORY
Medication Reconciliation Project Winnipeg Regional Health Authority

2 OUTLINE Information Sources Challenges with difficult clients
Questions to Ask Tips for Performing Medication History Reconciliation and documentation Client Education Tools

3 Information Sources Patient Family or Caregiver
Medication Vials / Bubblepacks Medication List Community Pharmacy Medication Profile from other facility DPIN (Drug Programs Information Network) Use multiple sources of information if need be.

4 CHALLENGES with Difficult clients
Belief – physician has information Unfamiliar with medications and names Difficulty recalling Medicated clients (sedated, confused) Disease affects mental status Language barrier Hearing impairment Elderly clients Caregiver administers or sets up medications Medication vials or list unavailable If patient can not remember a medication or if clarification is needed: Get a description of the medication from the patient or family member (form, strength, size, shape, color, markings) Contact family member that could possibly bring in the medication or read it over the phone Call the patient’s pharmacy Contact the specialist’s office or other physician to get an accurate list of medications Obtain previous medical records

5 Interviewing the client
Introduce yourself Inform client of reason for you being there Inform client of importance of maintaining a current medication list in chart

6 QUESTIONS to ASK Which community pharmacy do you use?
Any allergies to medications and what was the reaction? Which medications are you currently taking: The name of the medication The dosage form The amount (specifically the dose) How are they taking it (by which route) How many times a day Any specific times For what reason (if not known or obvious) How many do you take at a time? Do you have to cut the tablet?

7 QUESTIONS to ASK What prescription medications are you taking on a regular or as needed basis? What over-the-counter (non-prescription) medications are you taking on a regular or as needed basis? What herbal or natural medicines are you taking on a regular or as needed basis? What vitamins or other supplements are you taking?

8 Medication History Taking TIPS
Balance open-ended questions (what, how, why, when) with yes/no questions Ask non-biased questions Avoid leading questions Explore vague responses (non-compliance) Avoid medical jargon – Keep it simple Avoid judgmental comments Use non-biased questions that do not lead the patient into answering something that may not be true. Eg. Fosamax must be taken on an empty stomach first thing in the morning and you must remain upright for 30 minutes. That is how you are taking it, right? Avoid judgmental comments such as: I see that you have been on lorazepam for quite some time, you’re likely addicted to them.

9 Medication History Taking TIPS
Various approaches can be used: 24 hours survey (morning, lunch, supper, bedtime) Review of Systems (head to toe review) Link to prescribers (family physician, specialists)

10 Medication History Taking TIPS
Prompt for: Pain medications Stomach medications Medications for bowels Sleeping aids Samples Prompt for: Eye or ear drops, nose sprays Patches, creams & ointments Inhalers (puffers) Injections (needles) Prompt for non-pill dosage forms and prns

11 Medication History Taking TIPS
If medication vials available: Review each medication vials with patient Confirm content of bottle Confirm instructions on prescription vials are current If medication list available: Review each medication with patient Confirm that it is current If bubble packs available: Confirm patient is taking entire contents

12 Other QUESTIONS Have you recently started any new medications?
Did a doctor change the dose or stop any of your medications recently? Did you change the dose or stopped any of your medications recently?

13 Additional Questions to Explore Effectiveness/Compliance
Are any of the medications causing side effects? Have you changed the dose or stopped any medications because of unwanted effects? Do you sometimes stop taking your medicine whenever you feel better? Do you sometimes stop taking your medicine if it makes you feel worse?

14 Cards for Medication History Script
ALLERGIES • Do you have an allergy to or avoid any medications due to side effects? • What type of reaction do you have? PRESCRIPTION MEDICATIONS • What prescription medications do you take on a regular basis? • When do you take them? NON-PRESCRIPTION MEDICATIONS • What non-prescription over-the-counter (OTC) medications do you take on a regular basis? HERBALS/SUPPLEMENTS/VITAMINS • What herbal, natural or homeopathic remedies do you take? • What vitamins or minerals do you take? • ADDITIONAL QUESTIONS Do you use any: • eye drops • nose sprays • puffer (inhalers) • medicated lotions or creams • medicated patches Do you receive any: • needles (injections) • samples from the doctor’s office Do you take any medication on a regular basis: • for sleep • for your stomach • for your bowels • for pain

15 Reconciliation and Documentation
Upon discovering a discrepancy Update the list if minor (eg OTC) Include medications prescribed by other physicians (eg specialist) Inform physician if client is not taking as prescribed Document in the client’s chart The date MedRec completed and initial on the medication status record Any pertinent information in the progress notes Preparation of needed prescriptions Question: how do you handle medications that patient is not taking as prescribed eg: ?update list ?note in chart ?discuss with physician

16 Client Education Encourage ownership
Educate client to bring medications from home at each appointment Educate client to carry a list of current medications (prescription and OTC) Encourage family members/ caregivers to become involved Encourage one pharmacy

17 TAKE IT ALONG! Your PERSONAL MEDICATION RECORD
WRITE out on a piece of paper all prescription and over-the-counter medications (do not forget to include herbal and natural medicines) CARRY it with you at all times to keep everyone INFORMED SHOW it to your family physician, specialist, or other health care provider at each appointment, including all Emergency Room visits Remember to keep your medication list CURRENT by including all changes in medication or dose If you need help creating or updating your medication list, do not be afraid to ASK for assistance (family member or health care professional) A Medication Record booklet can be provided upon request by the clinic

18 TOOLS for clients – creating a list
R&D Knowledge is the best medicine booklet Medication Cards Piece of paper, notebook Assist when required

19 My current medications include:
My name is: _________________________________________________ My pharmacy is: ______________________________________________ I am allergic to: _______________________________________________ The medications that I can’t take because I have had side effects are: (please describe the side effect) ________________________________________________________________________ ________________________________________________________________________ My current medications include: Name of medication Why do you take it? What does the medication look like? What is the dose? How often do you take it? When did you start taking it?

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