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Taking Medication Histories

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Presentation on theme: "Taking Medication Histories"— Presentation transcript:

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


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