Get Medication History Medical

This process comprises five steps: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient.

Medication reconciliation involves a three-step process: verification (collecting an accurate medication history); clarification (ensuring that the medications and doses are appropriate); and reconciliation (documenting every single change and making sure it “squares” with all the other medication information).

Four-step process Verify (collect a current medication list) Clarify (make sure the medications and doses are appropriate) Reconcile (compare new medications with the list and document changes in the orders) Transmit (communicate the updated and verified list to the appropriate caregivers).

A good medication history should encompass all currently and recently prescribed drugs, previous adverse drug reactions including hypersensitivity reactions, any over-the counter medications, including herbal or alternative medicines, and adherence to therapy.

The “gold standard medication history” is created by a licensed pharmacist interviewing the patient to identify what medications the patient was taking prior to admission to the hospital.

The medication reconciliation SOP requires implementation of a standardised process of medication reconciliation whenever care is transferred. That is, on admission, transfer within the hospital and on discharge from hospital to home or a long term care facility (nursing home).

CMS requires that medication reconciliation and management be provided to patients on or before the face-to-face visit date. As AAFP states, "Transitional care management medication reconciliation requires the medications on discharge to be reconciled with the medications the patient was taking previously."

The following information is commonly recorded 4: Currently or recently prescribed medicines. OTC medication. Vaccinations. Alternative or traditional remedies. Description of reaction and allergies to medicines. Medicines found to be ineffective. Adherence to past treatment courses and the use of adherence aids.