Best Possible Medication History: A Clinical Pharmacist′s Comprehensive Guide

For Clinical Pharmacists, taking a Best Possible Medication History is second nature. However, with medications having a higher risk of errors and adverse events compared to other health interventions, the process for students, interns, and junior doctors can seem overwhelming1.

A medication history is a comprehensive?list of all the medications a?patient actually took?in the time leading up to admission or presentation for the episode of treatment. Obtained by a history interview and background information review it also contains details on recent changes or discontinuations to the patient's medications as well as information about prior adverse drug reactions and adverse medication events2. This document is used for the duration of the patient’s hospital stay, thus incorrect or incomplete documentation can significantly impact a patient′s treatment plan and health outcomes.

Here I break down the process of obtaining a BPMH, share insights from my clinical experience and couple these with my research on how best to take a BPMH.

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Preparation Before Meeting the Patient

Review Existing Information: Before talking to a patient, review their notes, especially the medical admission note. Often, valuable details are already documented, reducing repetitive questioning.

Medication Check: Check if the patient has brought their home medications into the hospital. Having visual confirmation of the patient’s medications saves time and allows the pharmacist to understand the patient′s adherence, verify doses and formulations.

Digital Health Records: Check any available digital health platforms, like My Health Record in Australia the ePA (die elektronische Patientenakte) in Germany, for added information.

Laboratory Results: Check and document relevant laboratory results such as renal function, electrolytes, liver function, full blood count, cardiac markers, and general observations as they impact medication decisions.

My preference is to complete as many details as possible before I interview the patient. ?This gives the patient the perception of organisation and professionalism, which enables me to build initial trust with the patient. It also prevents me from doubling up on questions that the medical team may have already asked and documented and allows me to prepare additional questions that I will ask the patient during our interview.

Tailor your interview to suit the individual patient. Only ask relevant questions as an exhaustive interview may be ineffective.

Use a checklist. No matter how much experience you have, well-designed checklists can improve outcomes3.

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Initiating the BPMH Interview

Greet the patient using AIDET, a communication framework for healthcare professionals to communicate with patients in a way that reduces patient anxiety, increases patient compliance, and improves clinical outcomes?.

Acknowledge the patient by name, acknowledge family or friends in the room. Introduce yourself by name and profession. Give an indication of the expected Duration of the interaction, Explain what you are doing and Thank the patient after the interview?.

e.g. Hi, (patient′s name) I′m Jess, the pharmacist on your treating team, I am working with the doctors and nurses on the (X) team.

Give the patient a reason for your visit.

I am here to discuss your medicines, how you usually take them at home and your medical history.

Establish Consent: Before diving into questions, ensure the patient is comfortable and that you are in a private space. If you′re not in a private space, which is not always possible, ensure the patient is consenting to the interview in the location that you′re in. Provide them with an estimation of how long the interaction might take. The patient has the right to decline an interview, which should be respected2.

This will take approximately 15 minutes, is it okay with you if we discuss this now?

Identify the patient using three points of identification before commencing your interview.

May I please confirm your full name, date of birth and address before we begin?

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Components of a BPMH

Patient Background and Medical History

• Presenting Complaint: Even if this is in the admission note, it's crucial to document this in your note. It guides the assessment of the impact of medications on the current complaint.
• Past Medical History: Gain a thorough understanding of the patient′s medical history and past surgeries. This is usually well documented in the medical admission note, however pharmacists will ?also match the patient′s medications to the medical history to see if there are any medical conditions missing from the history or if there are any medications that are potentially unwarranted (see home medications section below). Ask females of child-bearing age if they are currently pregnant or breastfeeding as this could affect their medication management.
• Allergies: Complete a list of drug allergies, the reactions they caused, when they occurred and whether the patient was hospitalised for the reaction.
• Medical Provider Details: Gather details about the patient’s General Practitioner, specialists they visit, residential aged care facility details (if applicable) and their community pharmacy. You may need to use this information to contact the medical providers for queries or confirming medication prescriptions or doses. When gaining this information, ask for the patient′s consent to contact their medical providers.
• Social History: Understand the patient's lifestyle, smoking habits, illicit substance use and alcohol consumption and document this in the social history section. This is often already assessed in the medical admission note, so check that first. Undertake a smoking assessment for smokers and offer support in quitting, including nicotine replacement therapy if appropriate.
• Height and Weight: May be needed for medication dosing. E.g, “For the purposes of medication dosing, it is useful for us to know how much you weigh, do you have a recent weight measurement?”

Medication Management

• Medication Administration: Ask the patient, who manages their medications and, if they use any dose administration aids. Knowing who manages the medications is important as this is likely who you will give medication counselling to upon the patient′s discharge.
• Home Medications: Start with an open-ended question: what medications do you take at home? Document all medications the patient is taking, including non-prescription, herbal supplements and complementary medicines including the name of each medication, the formulation, the dosage, route and frequency.Ask the patient what indication they are using each medicine for. Check for any mismatches between the medical condition and medications and look for any recent changes to the medication regimen.Prompt the patient for specific medications that are often forgotten such as; eye drops, ear drops, nasal sprays, inhalers, creams, ointments, patches, injections, implants, contraceptives (if relevant).Ask if they take any medicines once a week, once a month or when needed. Ask about medications for specific conditions: e.g. what medicines do you take for your high blood pressure? Ask about medications prescribed by specialists. Ask what each medicine is for.
• Adherence: Many patients have difficulty taking their medications exactly as they should every day. How many days have you missed a dose of your [medication name] in the last week?
• Ability to communicate: The patient's cognitive function, language barriers, alertness, mental acuity and any communication needs, such as the need for glasses, hearing aids, or an interpreter, should all be considered and documented when determining their ability to communicate2.
• Drug Monitoring: Inquire about any drug monitoring for example International Normalised Ratio (INR) for patients on warfarin including the date and result of the last INR. Another example is clozapine; before validating or dispensing this drug, pharmacists must consult a database called ClopineCENTRAL in order to track a patient's health indicators and prevent major adverse reactions associated with clozapine.
• VTE Prophylaxis: Assess whether the patient requires venous thromboembolism (VTE) prophylaxis and document your advice. This is commonly missed in the medical admission note and is an area that pharmacy can add value by reminding the medical team to consider this along with your recommendation for prophylaxis if appropriate.
• Immunisation Status: Document recent immunisations. This is especially important in patients who are receiving a transplanted organ.
• Other Assessments: Identify barriers to medication adherence such as dexterity, cognition and swallowing ability, recent antibiotics, or recent changes to medications. This may help to understand the patient's current state better.Recent changes to medications can sometimes be a contributing factor to the patient′s admission. Always think about the patient′s reason for admission from a pharmacy and medicines standpoint. Could any aspect of their medication regimen have contributed to their hospital admission? e.g. adverse drug reaction, poor adherence, inadequate dosing, inappropriate therapy1.
• Medications Required on Discharge: Check what medicines the patient has existing supplies of and what medications require supply on discharge.

Other

• Additional Assessments: include any other relevant details here such as a bowel assessment and/or pain assessment if appropriate.
• Check Available Databases for Access to High Risk Medicines: In Victoria, Australia, pharmacists must check SafeScript, a clinical tool that provides access to a patient′s prescription history of certain high-risk medicines prior to verifying or dispensing a prescription for a medicine that is monitored through this system.
• Source of Information: Document where your information is from - be it the patient, carers, previous notes, digital records, previous prescriptions, patients own medicines brought into the hospital, GP medication list, transfer information from another health service, pharmacy dispensing records etc.

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Other things to consider: Interview environment

It's essential to ensure the environment is conducive for the interview. Ensure:

• The patient is comfortable.
• You have minimised distractions and interruptions.
• You maintain effective non-verbal communication, like eye contact to aid in building rapport.

Thank the patient at the end of the interview.

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Communication Skills

• Open Ended Questions: Ask open-ended questions. Their use increases the amount of information gathered from patients?. Keep your language simple, avoid medical jargon. Always encourage patients to ask questions if something is unclear. Instead of asking ′Do you have any pain?′ a more effective question would be ′Can you describe any discomfort you are experiencing?′
• Teach-back: Teach-back includes having patients rephrase what a medical professional has just said. This allows for miscommunications to be determined and gives the health professional the opportunity to evaluate the patient′s understanding. Continue reiterating until the patient is able to accurately recall the information supplied?.
• Observation: Monitor non-verbal cues. Discrepancies between what is said and the patient's body language can tell you a lot of information. Patients frequently struggle to clearly communicate their preferences and needs?. Healthcare professionals need to be able to identify and comprehend patients' feelings, motivations, and values to respond to them appropriately?.
• Empathy over Sympathy: Relate to their feelings instead of feeling sorry for their situation.
• Active Listening: Listen to and understand what the patient says. Don′t have a rigid, rehearsed interview, as no two patients are exactly the same. Ask questions specific to the patient, their medicines and medical conditions to ensure vital information is not missed.
• Recognising Critical Information: Stay vigilant for any 'red flags' in the patient's medication history. Ensure?that the treatment of the presenting complaint will not exacerbate an existing condition by looking for any potential drug and/or disease contraindications. Take into account treatments for pre-existing?conditions that may?have been omitted2.?

If you're unsure about something, check your resources and/or seek advice from your line manager, a colleague, or your medical team. It's always better to ask than to assume.

Documentation

Proper documentation of patient interactions ensures a clear communication pathway for other healthcare professionals, thus aiding in optimal patient care. By adopting a structured approach, you ensure that your notes are not only comprehensive but also easily understandable. Your documentation acts as a legal account of a patient's medical treatment, which can be referenced in situations such as malpractice claims or other legal actions?.

The SOAP note is a proven method for documentation, especially when obtaining a best possible medication history:

• Subjective: Details provided by the patient or carer, such as symptoms they describe, known allergies, relevant social or family history, and other patient information.
• Objective: Information that can be independently verified, such as the list of the patient's current prescription drugs, along with information on dosage, frequency, and route, observations on medication adherence, and pertinent results from physical exams and tests.
• Assessment: Document your professional evaluation of the patient′s current condition or needs. This includes an assessment of actual or potential medication-related problems.
• Plan: Outline your recommendations for the patient′s management from a pharmacy and medicines standpoint. Document actions to be taken, how to monitor the patient′s clinical response and any monitoring required. ?

The essence of good documentation lies in its clarity, preciseness, and relevance. While comprehensive details are crucial, it's equally essential to be succinct.

Involvement and Continuous Learning

Remember, the patient is a vital resource. They know their body and experiences best. Ensure they're a part of the decision-making process. As you progress, continuously seek feedback and learn from your experiences.

Conclusion

Taking a BPMH is an skill that combines clinical knowledge, observational skills, and effective communication. It's a crucial part of patient care, ensuring safe and effective medication management. By following this guide, completing training using verified resources and consistently refining your skills, you can master this process, providing invaluable care to your patients.

The process of medication reconciliation, which is carried out after obtaining a BPMH and involves comparing the BMPH to medication orders for presentation, transfer, or discharge within the context of the patient's Medication Management Plan (MMP), follows2.

Thank you for reading. If you found value in this article, please hit the like button and repost. Comment below with any questions, and as always feel free to connect if you′re in the same or similar industry.

Disclaimer: Please note that this is a general summary of a BPMH. I am not affiliated with the Pharmacy Board of Australia, AHPRA, or the Australian Pharmacy Council. All content provided here is a result of my personal experience, accumulated knowledge and the references below.

References:

1. Roughead E, Semple S. Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002–2008. Aust New Zealand Health Policy 2009;6(1):18.
2. SHPA Standards of Practice for Clinical Pharmacy Services. (2013). Chapter 1: Medication reconciliation. Journal of Pharmacy Practice and Research, 43(2S), S6-S12. Retrieved from ??????????://??????.????????.??????.????/????????????????????????/????????????????-????????-????????-????????-????????????????????????/??????????????%??????%????-%????????????????????????%????????????????????????????????.??????
3. Gawande, A. (2009). The checklist manifesto: How to get things right. Metropolitan Books.
4. Studer Group. (n.d.). AIDET: Acknowledge, introduce, duration, explanation and thank you. Gulf Breeze: Author. Retrieved from ??????.??????????????????????.??????/??????????
5. Takemura, Y., Sakurai, Y., Yokoya, S., Otaki, J., Matsuoka, T., Ban, N., Hirata, I., Miki, T., & Tsuda, T. (2005). Open-ended questions: are they really beneficial for gathering medical information from patients? Tohoku J Exp Med, 206(2), 151-4. ??????????://??????.??????/????.????????/????????.??????.??????. ????????: ????????????????.
6. American Medical Association (AMA). (2006). Health Literacy and Patient Safety: Help Your Patients Understand. AMA Foundation; Chicago, IL.
7. Hall, J. A., Harrigan, J. A., & Rosenthal, R. (1995). Nonverbal behavior in clinician—patient interaction. Applied and Preventive Psychology, 4(1), 21-37. ??????????://??????.??????/????.????????/??????????-????????(????)??????????-??
8. Hall, J. A. (2011). Clinicians’ accuracy in perceiving patients: Its relevance for clinical practice and a narrative review of methods and correlates. Patient Education and Counseling, 84(3), 319-324. ??????????://??????.??????/????.????????/??.??????.????????.????.??????.

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