Medical Notes - Patient Medical History

What Medication History Or List To Take From Patients?

It is not easy to keep track of the medication that your patients might be taking. Usually, patients keep track of the medication they are using, so that they can communicate the list to their health care providers correctly. However, as a health care professional, it is important for you to have a complete know-how of medication history or lists.

A medication history is the collation of all current medications taken by a patient. The medication list and histories can help avoid problems such as over dosing, wrong scheduling or duplication of medication. Getting an accurate medication list and history is imperative for medication reconciliation. It can help avoid issues with medication problems and unnecessary hospital admissions. The difference between medication lists and medication histories can be summed up as; medication list is frequently used in the outpatient scenario whereas medication history is more frequently used in the inpatient scenario.

Things To Be Included In Med List Or History

When starting the practice of medicine, you are provided with policies and procedures regarding the information needed to collect from patients. Here are some general guidelines that must be included in a patient’s medication list or history.

  • A comprehensive medication list or history should include all the medications that a patient is taking. The medication could be oral (capsules, syrups etc.), topical (Creams, ointments etc.), drops, injections, inhalers, etc. It should include supplements and any other over the counter medications as well.
  • Many patients do not consider supplements or over the counter medications as a part of medication list or history. However, these products can cause severe drug interactions that could be fatal. So, it is imperative to include these non-prescription products in the medication list or history.
  • If you are taking medication history for admitting a patient in hospital, you need to learn about any OTCs or supplements.
  • Immunization history is also imperative for patients who require vaccines for influenza or any pneumococcal vaccine.
  • A medication history should also include the use of recreational drugs such as marijuana. Drinking of alcohol is another parameter that needs to be checked while getting an accurate medical history. Alcohol and recreational drugs can interact with prescription drugs and the results can be catastrophic.
  • Smoking history should also be included as tobacco can interact with some medications and cause severe effects.
  • The dose and dosing schedule of current medication should be included along with date of start and stop of the medications.
  • If a person can’t tell the kind of medications they are on, get the physical characteristics of the medication such as color, shape and any kind of markings on the medication.
  • A complete list of patient’s allergies needs to be included in the med list or history as well. From drugs to foods and any environmental allergies along with reactions should be listed.

We hope these guidelines would help you get a better medication history from patients. Share your thoughts with us in the comments below.

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