History – Best Possible Medication History (BPMHx)

A thorough medication history is crucial for effective patient care, ensuring safe prescribing practices, and preventing adverse drug events. Here’s a guide on how to obtain and document the best possible medication history:

1. Preparation

  • Environment:
    • Ensure a quiet, private setting to facilitate an open conversation.
  • Tools:
    • Have a standardized form or electronic health record system ready to document the information.

2. Introduction

  • Introduction and Purpose:
    • Introduce yourself and explain the purpose of taking a medication history.
  • Consent:
    • Obtain consent to discuss and document the patient’s medications.

3. Patient Information

  • Demographics:
    • Verify the patient’s full name, date of birth, and any relevant identification numbers.

4. Current Medications

  • Prescription Medications:
    • Document all current prescription medications, including:
      • Name of the drug (brand and generic names)
      • Dosage and frequency
      • Route of administration (oral, topical, etc.)
      • Indication (reason for use)
      • Start date and duration of use
  • Over-the-Counter (OTC) Medications:
    • Include all non-prescription medications, vitamins, and supplements with the same details as prescription drugs.

5. Past Medications

  • Discontinued Medications:
    • Record medications taken in the past, including reasons for discontinuation (e.g., adverse effects, lack of efficacy).

6. Allergies and Adverse Reactions

  • Drug Allergies:
    • Document any known drug allergies and the type of reaction experienced.
  • Adverse Drug Reactions (ADRs):
    • Include details of any ADRs, even if not classified as allergies.

7. Social History and Substance Use

  • Alcohol and Tobacco:
    • Document the patient’s use of alcohol, tobacco, and other substances.
  • Illicit Drugs:
    • Ask about the use of any illegal drugs or substances.

8. Adherence and Barriers

  • Adherence:
    • Assess the patient’s adherence to their medication regimen. Ask about missed doses and reasons for non-adherence.
  • Barriers:
    • Identify any barriers to adherence, such as cost, side effects, or complexity of the regimen.

9. Sources of Information

  • Patient/Caregiver:
    • The primary source of information is the patient or their caregiver.
  • Pharmacy Records:
    • Contact the patient’s pharmacy for additional details or confirmation.
  • Previous Medical Records:
    • Review the patient’s past medical records for historical medication information.

10. Documentation

  • Accuracy:
    • Ensure the information is accurately recorded, and double-check for any inconsistencies.
  • Updates:
    • Regularly update the medication history, especially after any changes in the patient’s regimen.

11. Review and Confirmation

  • Review:
    • Summarize the information and review it with the patient to confirm accuracy.
  • Confirmation:
    • Obtain confirmation from the patient or caregiver that the medication history is complete and correct.

12. Communication

  • Healthcare Team:
    • Share the medication history with the entire healthcare team to ensure coordinated care.
  • Patient Education:
    • Educate the patient about their medications, including the importance of adherence and potential side effects.

Key Points to Remember

  • Thoroughness: A comprehensive medication history is essential for patient safety.
  • Verification: Cross-check information with multiple sources when possible.
  • Continuity: Maintain an up-to-date record to prevent errors and omissions.

By following these steps, healthcare providers can ensure they gather the most accurate and complete medication history, which is fundamental for delivering safe and effective patient care.