10 Steps to Take an Accurate Inpatient Medication History


Using a standardized method for taking medication histories is vital to minimizing errors.

Taking medication histories can be difficult. Many patients don’t manage their own medications, and many of those who do struggle with drug names, doses, and indications.

Using a standardized method for taking medication histories is vital to minimizing errors. Here are 10 steps to do so:

Step 1: Introduce yourself to patients and ask for permission to discuss their home medications.

If there are guests in the room, offer to come back later instead of asking whether it’s ok to speak in front of others. This takes the burden off of patients and gives them an easy avenue to decline discussing their medications in front of guests.

Step 2: Check each patient’s name and date of birth.

Step 3: Ask whether they came to the hospital from their home or a facility, if you’re uncertain.

Oftentimes, patients coming from a nursing home or other care facility will have a W-10 form that can be used to obtain their current medications.

Step 4: Ask whether they manage their own medications or if someone helps them.

Before spending a significant amount of time trying to obtain a medication history from patients unfamiliar with their medications, ask if someone assists them. For example, many patients have family members who set up their medication box. It may also be a good idea to inquire about a visiting nurse who assists with their medications.

Step 5: Ask about the name, strength, dose, route, and frequency of their medications.

This question may be overwhelming for patients on many different medications, so encourage them to start anywhere they remember. Although it may be tempting to read their current medication list and ask whether it’s correct, there’s a lot of room for error in this method. Instead, try prompting the patient by asking, “Do you take any medications to lower your cholesterol?”

Step 6: Ask about OTC products, vitamins, and any medications taken less often.

Aspirin is an important medication that patients might forget to mention.

Step 7: Ask about inhalers, injectables, creams/ointments, eye drops, ear drops, nasal sprays, patches, and medication samples.

Patients often associate the word “medication” with pills, so prompting them with other dosage forms can remind them of medications they might have missed.

Step 8: Ask which pharmacy/pharmacies they use and inquire about allergies.

Step 9: Thank them and ask whether they have any questions.

Using the phrase “I have the time” has been proven to increase a patient’s willingness to ask questions.

Step 10: Evaluate the medication history obtained against at least one additional source.

The sources should contain the same medication names, strengths, dosages, routes, and frequencies. Any discrepancies should be further investigated. Some examples of secondary sources are previous medication list, prescription bottles, pharmacy records, and insurance records.

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