Medication History: Verification, Clarification

• Collecting an accurate medication list for patients is important when they transfer care between facilities
• An accurate medication list should include these three elements: verification, clarification, and reconciliation
• Best practices for medication reconciliation should be incorporated
• Medication history is a detailed, accurate, and complete account of all prescribed and non-prescribed medications a patient has taken or is currently taking
• Medication history provides insights into a patient's allergic tendencies, adherence to pharmacological and nonpharmacological treatments, and self-medication with complementary medicines
• Taking accurate medication history prevents prescription errors and consequent risk to patients
• It is useful in detecting drug-related problems
• It assesses the appropriateness of a patient's current therapy and directs future treatment choices
• Drugs can alter the results of investigations
• An example of a drug that alters test results is amiodarone, which alters thyroid function tests
• Taking an accurate medication history assesses patient medication compliance
• It provides an opportunity to educate the patient about their medications
• Sources of information for taking medication history include patient/patient's chart, family/caregiver, physician/other health care professionals, pharmacy, nursing home record, and patient's medical record

Components of Medication History

• Demographic data is a component of medication history
• Social history is a component of medication history
• Medications (prescription, non-prescription) are a component of medication history
• Complementary and alternative medications are a component of medication history
• PRN (as needed) medications a component of medication history
• Immunizations are a component of medication history
• Allergy info is a component of medication history
• Adverse drug reactions are a component of medication history
• Dietary information is a component of medication history
• Adherence information is a component of medication history

Demographic Data

• This includes the patient's age, height, weight, race, or ethnic origin
• All of these factors influence decisions regarding the selection of prescription and nonprescription medication, the dosage of the medication, and the therapeutic regimen
• Example: The patient is a 61-year-old WM (DOB 7/15/48) who is 5' 10" and weighs 116 kg

Social History

• Social history includes information about alcohol and illicit drug use
• It also includes occupation and the housing environment
• Details of tobacco smoking are taken down in a quantified manner

Current Prescription Medications

• Knowledge of current prescription medications allows evaluation of efficacy and safety of prescribed regimens
• It is important to obtain a complete list of the patient's current prescription medications, including name and dosage of the drug
• Must also document dosing schedule, duration of therapy, the reason the patient is taking the medication, and outcome of therapy
• Example: Hydrochlorothiazide (Esidrex) 50 mg daily for 5 years for high blood pressure. The patient doesn't think it works very well because her blood pressure is always high.

Current Non-Prescription Medications

• Important to obtain a complete description of current nonprescription medications from the patient
• Name and dosage of the drug, recommended and actual dosing schedule, dates and duration of therapy, reason the patient is taking the medication, and outcome of therapy should be documented
• Example: The patient is currently using bacitracin ointment on a cut on his finger. He applies a thin layer of bacitracin to the cut twice a day and started using it 2 days ago after accidentally cutting himself. The wound is healing well.

Past Prescription Medications

• Knowledge of past prescriptions helps pharmacists understand the medications used to treat current and past medical problems
• Important to guide recommendations regarding new medication regimens
• All required information about past prescription medications should be obtained
• Example: The patient was diagnosed with hypertension 5 years ago, initially taking hydrochlorothiazide 25 mg daily for 2 years then was switched to Vasotec (enalapril) 5 mg daily for 3 years before being switched to his current medication because his blood pressure was still too high.
• Knowledge of past nonprescription regimens gives the pharmacist insight regarding past medical problems or attempts to treat current medical problems
• Information on past nonprescription medications should be obtained
• Example: The patient takes Benadryl (diphenhydramine) 50 mg one capsule at bedtime for insomnia, having started using it 5 years ago, taking 4 or 5 doses two or three times a year, and last took it 2 months ago. Says it works well.

Current and Past Complementary and Alternative Medicine

• A complete description of current and past alternative medicine use must be documented
• Herbal remedies, acupuncture, and aromatherapy are examples of information to obtain
• The pharmacist should document the name, dosage, schedule, duration, reason, dates (start and stop), timing of use, and outcome of therapy
• Example: The patient takes milk thistle 200 mg three times daily “for my liver,” having started it 6 months ago, and believes it is working to keep her liver healthy

On Demand (PRN) Medications

• Medicines that are taken "as needed" are known as “PRN” medicines
• "PRN” is a Latin term that stands for “pro re nata," which means “as the thing is needed."
• Document the possible use as well as the patient's actual use of the prn medication
• Quantification is important; do not accept imprecise descriptive terms
• Example: Acetaminophen 650 mg every 4 to 6 hours as needed for headache for 50 years. The patient takes one to two doses per month and says it is very effective.

Immunization

• It is important for the pharmacist to obtain and maintain an accurate immunization record as part of the medication history
• The name of the vaccine and the date the vaccine was given should be recorded
• Record the information the patient can supply, even if the patient may not know the specific details
• Example: Tdap (tetanus, diphtheria) 2005; pneumococcal polysaccharide 2009; zoster 2007; influenza 2009, COVID-19 2021

Allergy

• Drug-induced allergic reactions include anaphylaxis, contact dermatitis, and serum sickness
• Patients should be asked whether they are allergic to any medication or if they have experienced rashes or breathing problems after taking medication
• After a medication has been identified as the cause of an allergic reaction, the patient should provide details regarding the time or date of the reaction and any interventions to manage the reaction
• Patients should be asked whether medications in similar drug classes have been taken without similar reactions
• No allergy: if you are sure that the patient is not allergic to anything
• NKDA: Not Known Drug Allergy (if you are not sure of patient allergy)
• All other types of allergies should be asked about (food allergy, insect allergy, others)
• Example: The patient is allergic to penicillin, experiencing an itchy rash all over his whole body after taking a couple doses 20 years ago, and has not taken penicillin since then

Adverse Drug Reactions

• Adverse drug reactions (ADRs) are unwanted pharmacologic effects associated with medications
• The name of the medication, its dosage, and the reason the patient was taking the medication should be determined
• Also determine the date of the reaction and details of the adverse reaction, and how the patient dealt with the reaction
• Example: The patient felt dizzy and had strange dreams after taking one dose of Darvon (propoxyphene) 10 years ago for pain after some dental work, so he threw out the rest of the prescription and has not taken Darvon since then

Dietary Information

• Dietary information includes dietary intake and any specific dietary restrictions
• Dietary information is an important component of the medication history because some drug therapies may appear ineffective if the patient is nonadherent to recommended dietary restrictions
• Patients with congestive heart failure may not comply with salt-restricted diets
• Patients may suffer from adverse effects due to drug-food interactions

Adherence

• Medications may be ineffective if the patient does not comply with the prescribed or recommended regimen
• Adherence is difficult to determine through direct questioning - patients most likely will say they are adherent even if they are not
• Clues about adherence may be obtained through patient descriptions of how they take their prescribed medications
• Example: the patient is nonadherent and admits that she picks and chooses which medication to take and that she takes them how she wants to, not as prescribed

Top 10 Practical Tips on How to Obtain an Efficient, Comprehensive and Accurate Best Possible Medication History (BPMH)

• Be proactive, gather as much information as possible before seeing the patient
• Prompt questions about non-prescription categories: over the counter drugs, vitamins, recreational drugs, herbal/traditional remedies
• Prompt questions about unique dosage forms: eye drops, inhalers, patches, and sprays
• Don't assume patients are taking medications according to prescription vials - ask about recent changes initiated by either the patient or the prescriber
• Use open-ended questions: "Tell me how you take this medication?"
• Use medical conditions as a trigger to prompt consideration of appropriate common medications
• Consider patient adherence with prescribed regimens ("Has the medication been recently filled?")
• Verify accuracy: validate with at least two sources of information
• Obtain community pharmacy contact information: anticipate and inquire about multiple pharmacies
• Use a BPMH trigger sheet (or a systematic process / interview guide) - include efficient order/optimal phrasing of questions, and prompts for commonly missed medications

Challenges to BPMH

• Patients may not know all of the required information about their medications and/or it is possible that they may not keep an accurate list of their medications
• A patient is unable to effectively communicate medication information due to clinical scenario/medical condition or language barriers
• A patient does not bring all medication products with them for a care encounter
• Care providers lack education on how to conduct a BPMH/effectively communicate with patients
• Provider-specific IT systems do not maintain complete lists of a patient's medication(s) in their records
• When documented, medication information is not easily or reliably shared between care providers
• Access to systems that exist to share medication information may be limited or information may only be available for a portion of the population or for certain types of medications

Hindering Behaviors

• Using technical language and medical jargons
• Frequently interrupting the patient
• Asking leading questions
• Allowing frequent interruptions (phone calls, beepers)
• Avoiding eye contact with the patient
• Asking multiple rapid questions
• Ignoring emotion displayed by the patient
• Judging the patient
• Reading notes and charts during the interview

Medication Reconciliation

• Medication reconciliation is a patient safety initiative
• Obtaining an accurate medication history is the first step of the medication reconciliation process
• Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking, including drug name, dosage, frequency, and route, and comparing that list against the physician's admission, transfer, and/or discharge orders

Goals of Medication Reconciliation

• To prevent adverse drug events (ADEs) at all interfaces of care (admission, transfer, and discharge)
• To eliminate discrepancies by reconciling all medications at all interfaces of care
• To ensure patients receive the appropriate medications
• To minimize medication errors, including omissions and duplications, or drug interactions

How to Reconcile

• Reconciliation involves comparing the patient's current list of medications against the physician's admission, transfer, and/or discharge orders
• Each time a patient moves from one setting to another, pharmacists should review previous medication orders alongside new orders and plans for care and reconcile any differences

Who is involved in the reconciliation process?

• Disciplines involved are medicine, pharmacy, and nursing
• A significant, proven solution to improving medication reconciliation in hospitals and other healthcare settings is involving pharmacists and making them an integral part of the process
• When pharmacists provided admission drug histories, nearly 4,000 deaths were avoided

When does reconciliation occur?

• Admission
• Transfer
• Discharge

Steps for Medication Reconciliation

• Review the patient record prior to the interview
• Conduct medication history and establish BPMH
• Compare BPMH with the list of current medications
• Identify discrepancies and resolve with the prescriber
• Establish a new correct medication list