Medication history is a detailed, accurate, and complete information of
all the prescribed and non prescribed medications that a patient had taken or
currently taking in a hospital, ambulatory, or OP care.
It identifies patient’s needs and helps to improve the efficiency of medication by
rendering medication errors and concerns of illness and treatment.
It provides valuable information about patient’s allergies, adherence to
pharmacological and nonpharmacological treatments.
It serves as a starting point for other clinical activities like DI’S, ADR’S, Medication
1) To optimize patient’s drug therapy.
2) To appraise the drug administration techniques.
3) To prevent or minimize drug-related problems and medication errors.
4) To screen for potential drug Interactions
5) Assess for the evidence of drug abuse.
6) To prevent potential mortality and morbidity.
A) INTERVIEWING THE PATIENT:
This is mainly done to gather the information about the patient, identifying the potential
problems that he is facing, disease, and its duration. These are
1) Demography details of the patient.
2) Family history of the patient for any hereditary diseases and allergies.
3) Immunization status.
4) Regular habits like smoking, alcoholism, diet variations.
5) Previous consultations and treatment plans, duration of the therapy.
6) Reasons for discontinuation or alteration of medications.
7) Storage conditions of the medications if required.
8) Adherence to past treatment courses and use of adherence aids.
B) COMPONENTS TO BE DOCUMENTED:
Research has established that in routine
practice pharmacists provide the most accurate information when compared to other health care professionals. They are submitted to physicians for further evaluation.
1) Current consultation.
2) OTC Medications, vaccinations, and duration of therapy.
3) Alternative or Traditional remedies.
4) Patient-specific considerations like Pregnancy, disease status, allergies.
5) Record of the drug, dose, dosage schedule, dosage form, route of administration with
respect to age, renal function, and liver functions.
6) Medication intolerance or hypersensitivity.
7) Review of medication records for cost-effectiveness.
C) FOLLOW UP:
1) Identify and resolve drug-related problems.
2) Refill information, Missed doses
3) Lifestyle modifications.
4) Encourage patients for further assistance.