Prescribing Flashcards
Medication history
Will need to write the information down- sign and date it
1) Patient demographics and allergies (food, drugs, animals, materials)- reason for admission. When did the allergy occur
2) Drug history source of information eg. Patient and GP print out. Get patient to tell me first and then clarify with the print out.
3) Regular, PRN, acute medications (how often for latter 2). Length of treatment
4) Creams, inhalers, sprays, drops
5) Any recent changes to medications/ doses (also any short courses of antibiotics, steroids- what day of the course are they on)
6) Additional remedies eg. Vitamins, recreational drugs, supplements eg.
7) Adherence to medications- any compliance aids eg. A spacer/ do settle boxes. Are they tolerating the side effects
8) Plan for medications on admission- adverse effects of any meds on patients present state/ is the drug causing the present state?- document any changes you want to make eg. Hyperkalaemia, stop ramipril
9) Check drug interactions!!!
Recording a Medication History
Correctly enters the patient’s details, noting date and time of entry
Documents all medications taken currently and relevant medicines taken in the past, including approved name, dose, formulation, route, frequency, time of day
Records any reported patient experiences with regard to tolerability/side effects and perceived effectiveness Notes duration of treatment where relevant
Documents other medicines, e.g. over the counter, herbal/homeopathic
Records allergies/ intolerances, nature of reaction and date of occurrence (if known)
Details reported adherence to the prescribed regimen Documents sources of information used in obtaining a medicines history e.g. what the patient says with repeat prescription slip / relative/ med boxes
Signs entry and writes legibly, including their name and role- MOST IMPORTANT PART
Prescription Review
May need to write the information down.
1) Patient demographics- comment on age and gender (eg. pregnancy etc.). Also consider patients hepatic and renal function
2) Allergies and intolerances
3) Medicine indications- are these relevant to the conditions being treated. Do they need any drugs stopping?
4) Medicine dose, frequency, duration and route (check BNF to see if these are correct and consider age, weight, comorbidities and renal/liver function).
5) Check drug interactions, duplicated treatments eg. 2 diuretics or 2 antihypertensives and check for drugs with antagonist activity eg. Salbutamol and propranolol
6) Check comorbidities- may caution, contraindicate or require a different dose of a drug
7) Check legibility eg. Prescribers signature, black ink, hospital number etc.
8) Check adherence to treatment (say you would check this)
9) Check if they have had a VTE assessment- do they need any whilst they are an inpatient
10) Check whether appropriate monitoring has been carried out
NB- Where patients (or their carers) are available to talk to as part of a prescription review, asks about experiences, preferences and opinions with regard to their currently prescribed treatment
