Conducting a Medication History

What’s the Point?? To be an effective provider:

Perform/Obtain necessary assessments of the patient’s health status

Medication History can: Determine medical conditions Family History Social History Etc.

Health Literacy Level of understanding of disease state or

medication Patient may not know how to express details

otherwise Be sure to keep this information handy, as it

may be useful later

Developing a Relationship

Create Safe Environment

Patient feels more comfortable communicating Greet the patient with a smile Make eye contact Introduce yourself and verify the patient’s identity Emphasize your role as a caregiver Encourage complete, truthful report of information

Ask the Right Questions

Use a combination of open-ended and closed-ended questions

Combine this with active listening Open-ended

Encourages patient to expand on information Closed-ended

Reserved for confirming details and guiding discussion

Active Listening Interpret information to confirm, clarify or

encourage discussion Techniques:

Interpretation: “You have been asking a lot of questions…is there something worrying you?

Reflection: “You said ___. Tell me more about that” Clarification: “I don’t understand completely. Tell me

what you mean by ___” Empathy: “That must have been frustrating for

you…” Facilitation: “I’m listening…” Confrontation: “You appear to be…more than what

you’re saying”

Watch Non-Verbals Eye Contact

Make or break a relationship Shows either caring, or lack of interest

Patient Cues Fidgeting, closed body position could indicate

discomfort Acknowledge, be empathic – could help alleviate

Cultural Competence Ability to address patients with diverse values,

beliefs and behaviors Tailor delivery to meet patient’s social, cultural

and linguistic needs

Examine your own culture and beliefs… Think about mainstream health care model… Differences?

Note Taking Address early as a helpful tool Not judgmental Provides accuracy with record keeping

Patient Knowledge Gather information regarding

Preferences Attitudes Understanding Concerns Expectations Adherence

Can help you to tailor interventions to the patient

To Review… Introduce yourself – establish a relationship Be open and attentive to patient reports Collect pertinent information about medications

Names, doses, frequencies, believed indications Open-ended questioning Collect a complete picture of the patient