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Taking Medication Histories. EMTENAN ALHARBI ,Msc Clinical Pharmacy Department. Learning Objectives. Importance of medication history by pharmacist State the advantages & disadvantages of interviewing patients before and after review of patient information - PowerPoint PPT Presentation
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TAKING MEDICATION HISTORIES
EMTENAN ALHARBI ,Msc
Clinical Pharmacy Department
Learning Objectives
1. Importance of medication
history by pharmacist
2. State the advantages &
disadvantages of interviewing
patients before and after
review of patient information
3. Identify the most relevant
information from observing
patient surroundings
4. List the categories of data to
be collected during the
interview
5. Describe the type of
information under each
category
6. Differentiate between
allergy and ADR.
7. State how to assess patient
compliance.
8. Identify types of questions
to use and to avoid.
9. Discuss the different type of
documentation styles
2
Medication history.. Importance
Why pharmacists?
Errors attributed to incomplete Medication
History5
Errors of omission Errors of commission Incorrect dose Incorrect frequency Incorrect strength Incorrect name Incorrect dosage form
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
What are the sources for patient information?
7
Sources of Information for patient database
8
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
Steps for successful Medical History Session
9
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.
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
Interview patient with no background knowledge
Setting: community pharmacy
Advantage: Unbiased Allow for exploration
of all aspects equally Disadvantage:
Intimidating Time consuming
10
Preparation.. Observe Patient and his Surrounding
11
Patient state of health
Socioeconomic status
e.g. Cost of med.
Compliance with dietary
recommendations
e.g. Antihypertensive agent & salt restriction
Social support system
What type of information is included during a medication history session?
Data Collection
04/21/23
12
PHCL 326: communication skills for Pharmacists
Data to be Collected13
Demographic Information Age/date of birth Gender Height and weight Race and ethnic origin Residence Education Occupation Life style
Dietary Information15
Restrictions
Supplements
Stimulants
suppressants
Social Habits16
Tobacco:
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
Social Habits..Packs-Year17
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)
Social Habits..Example18
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 .
Current Rx medications19
Name/description
Dosage
Dosing schedule (prescribed, actual, PRN)
Indications
Date med started
Outcome of therapy
Past Rx medications
Name/description
Dosage
Dosing schedule (prescribed, actual, PRN)
Indications
Date med started
Date med stopped
Reason for stopping
Outcome of therapy
Current & Past OTC medication
21
Name/description
Dosage
Dosing schedule (recommended and actual)
Indications
Date med started
Date med stopped
Outcome of therapy
Reasons for stopping the med
Current & Past Alternative Remedies
22
Name/description
Dosage
Dosing schedule (prescribed and actual)
Indications
Date remedy started or stopped
Outcome of therapy
Reasons for stopping the med
Allergies23
Name & description of causative agent
Dosage
Date of reaction
Description of reaction
How the reaction was treated
Adverse Drug Reactions24
Name & description of causative agent
Dosage
Date of reaction
Description of reaction
How the reaction was treated
Immunization
Vaccines Date of administration
Compliance Assessment26
Causes of non-compliance ADR Cost Unavailability Inappropriate dosage form Not understanding the reason for taking
the medication Deliberate
Questioning Techniques27
Open-ended questions
Close-ended questions
Targeted questions
Leading questions
Setting the stage for the interview
28
Pay attention to communication skills
29
Avoid Hindering Behaviors30
After the Interview31
Document your medication history in patient file/chart Make sure to:
Write eligibly (print is preferred) Record Date & Time of the interviewYour initial and signature
Write SOAP for medication related problems indentified during the interview
Documentation32
Standardized Freestyle SOAP
Individual Assignment 36
Find a relative, neighbor or a friend and obtain a medication history from
Use the standardized data collection sheet