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Obtaining THE BEST POSSIBLE MEDICATION HISTORY

Obtaining THE BEST POSSIBLE MEDICATION HISTORY. Medication Reconciliation Project Winnipeg Regional Health Authority. OUTLINE. Information Sources Challenges with difficult clients Questions to Ask Tips for Performing Medication History Reconciliation and documentation Client Education

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Obtaining THE BEST POSSIBLE MEDICATION HISTORY

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  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)

  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

  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)

  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

  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. 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) Medication History Taking TIPS

  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: • Review each medication with patient • 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. 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? • When do you take them? HERBALS/SUPPLEMENTS/VITAMINS • What herbal, natural or homeopathic remedies do you take? • What vitamins or minerals do you take? • When do you take them? • When do you take them? • 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 Cards for Medication History Script

  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

  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 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:

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