[DISPENSING-LEC-FINALS] CH10: PATIENT MEDICATION PROFILE

Chief Complaint

CC stands for?

Family History

FH stands for?

History of Present Illness

HPI stands for?

Drug/Medication History

DH stands for?

Past Medical History

PMH stands for?

Pharmacy and Therapeutics Committee

PTC stands for?

Social History

SH stands for?

Review of System

ROS stands for?

Patient Medication Profile

Defined as a record of information on a patient’s drug therapy.

Patient Medication Profile

It is a current list of all medications prescribed for an individual, any allergies the individual has, and any information relevant to an individual’s ability to take medication safely.

Medication Histories

These are important in preventing prescription errors and consequent risks in patients.

Patient

Benefits of Patient Medication Profile:

Who’s the benefactor for reduced risk of medication error?

General Practitioner

Benefits of Patient Medication Profile:

Receives accurate, timely information that enables them to continue the patient’s care after discharge.

Hospital Doctor/Attending Physician

Benefits of Patient Medication Profile:

Safe foundation for prescribing new or acute medication.

Clinical/Hospital/Ward Pharmacist

Benefits of Patient Medication Profile:

Clear basis for managing medicines throughout the patient journey.

Nurse

Benefits of Patient Medication Profile:

Administers prescribed medicines with greater confidence.

Age

Identify the Factors:

The very young and the very old are most at risk of medication-related problems.

Gender

Identify the Factors:

May alter the choice of therapy for certain indications. It may also prompt consideration of the potential for pregnancy or breastfeeding.

Ethnic or religious background

Identify the Factors:

Racially determined predispositions to intolerance or ineffectiveness should be considered with certain class of medicines.

Social history

Identify the Factors:

This may impact the ability to manage medicines and influence pharmaceutical care needs, such as living alone or in a care home, or availability of nursing, social or informal careers.

Allergies

Identify the Factors:

Take note if the patient has allergic reactions to food or medication, type of reaction, and when the reaction occurred (recent or was it during childhood).

Immunization status

Identify the Factors:

Take note if the patient had a flu shot, a pneumococcal vaccine, COVID-19 vaccine, or a tetanus shot. Note when it was last received, unknown, or never took the vaccine.

Medication History Interview

This is a conversation with a purpose. Studying a patient’s history deeper will require interpersonal skills, only with some unique and critical differences.

Gather information

The goal of medication history interview is to?

Formal form of address

Identify the Skills:

Use patient’s title and last name.

Ex. “Good morning, Mr. Gerald.”

Rapport

Identify the Skills:

Use active listening skills to confirm interest in a patient and help gain respect.

Ex. “It’s not easy being in the hospital away from friends and family.”

Active listening/Emphatic responding

Identify the Skills:

Reflect on patient’s feelings or identify a patient’s underlying message.

Ex. “You sound unsure.” OR “Are you saying…?”

Open-ended questioning

Identify the Skills:

Patient is free to answer in any manner. This is useful when introducing a new subject.

Ex. “How are you taking your blood pressure medicine?”

Transition

Identify the Skills:

Verbally closing off one subject and introducing a new one allows the patient to make a mental transition.

Verbal following

Identify the Skills:

Technique to get the patient to elaborate on a subject without asking more questions, but simply repeating the patient’s last few words.

Ex." “…dizzy spells?”

Avoidance of leading questions

Identify the Skills:

Leading questions prompt the patient with a particular answer.

Avoidance of “why” questions

Identify the Skills:

“Why” questions can cause patients to get defensive. Rephrase questions to start with, “for what reason”.

Timing

Identify the Skills:

Warn a patient that a series of questions will follow.

Ex. “I am going to ask you a series of questions now.”

Clarity conflicting information

Identify the Skills:

Always accept the blame for inconsistent information that the patient may tell you or write.

Ex. “I must have written it incorrectly, I thought you had said…”

Silence

Identify the Skills:

Allow the patient to show emotion, digest information, or gather thoughts.

Ex. Maintain nonverbal facilitation and stop speaking.

Answering patient question

Identify the Skills:

Avoid definitive answers until a final drug therapy plan is devised.

Mentioning previously answered questions

Identify the Skills:

If a patient answers a question you were going to ask later in the interview, jot it down.

Ex. “You mentioned earlier that you occasionally take ibuprofen for headaches. Do you ever take anything else for aches or pain?”

Comprehensive patient interview

This interview includes inquiring about the patient’s medical, medication, social, personal, and family history, as well as a thorough review of systems and possibly a physical examination.

Chief Complaint

This refers to the medical issue that the patient has for the visit.

History of Present Illness

This is the story of the illness.

Location

Seven Attributes of a Symptom:

Specifics about where the symptoms are occurring.

Quality

Seven Attributes of a Symptom:

Describe the symptom in terms of characterization.

Quantity/Severity

Seven Attributes of a Symptom:

Quantify the severity of the symptom.

Timing

Seven Attributes of a Symptom:

Find out when the symptom started and if there was anything occurring at the time to link it to the onset of the symptom.

Setting

Seven Attributes of a Symptom:

This includes addressing the possible cause of the symptom.

Factors that aggravate or relieve the symptom

Seven Attributes of a Symptom:

Determine what makes the symptom better or worse.

Associated manifestations

Seven Attributes of a Symptom:

Note any other symptoms the patient is expecting. Also, ask about symptoms that may be a consequence if the primary symptom.

Past Medical History

This includes past diseases, surgical history, history of childhood illnesses, and obstetric or gynecologic history.

Surgical History

This should include the type of operation undertaken, when it was undertaken, and the indication for the operation.

Childhood Illnesses

Measles, mumps, chickenpox, whooping cough, rheumatic fever, scarlet fever, and polio.

Obstetric/Gynecologic History

This includes the number of pregnancies, even the deliveries, miscarriages, and terminations.

Health Maintenance/Immunizations

These include information on what immunizations the patient has received, such as influenza, pneumococcal, tetanus, COVID-19, and hepatitis B, as well as dates they were acquired.

Family History

This refers to the health information on the patient’s immediate relatives.

Personal and Social History

This is the part of the interview where we learn about the patient’s life, including health behaviors and personal choices.

Review of System

This is a systematic, head-to-toe evaluation of the presence or absence of symptoms.

Medication History

This has to be detailed and accurate. It has to be a complete account of all prescribed and nonprescribed medications of a patient, or patient’s medication prior to a newly initiated institutionalized or ambulatory care.

Medication History

This provides insight into the patient’s current and past medications, adverse drug reactions or allergies, adherence, the patient’s understanding about their medications, and any other concerns a patient may have regarding their medications.