Here is an outline for a script that any health care provider can use in the ED to ensure an accurate medication history — before discharge or before admission:
Introduction – Introduce self and profession
- I would like to take some time to review the medications you take at home.
- I have a list of medications from your chart/file, and want to make sure it is accurate and up to date.
- Would it be possible to discuss your medications with you (or a family member) at this time?
Medication Allergies
- Do you have any medication allergies? If yes, what happens when you take__ _?
Information Gathering
- Do you have your medication list or pill bottles (vials) with you?
- Show and tell technique when they have brought the medication vials with them.
- How do you take (medication name)?
- How often or when do you take (medication name)?
- Collect information about dose, route and frequency for each drug. If the patient is taking a medication differently than prescribed, record what the patient is actually taking and note the discrepancy.
- Are there any prescription medications you (or your physician) have recently stopped or changed?
- What was the reason for this change?
Community Pharmacy
- What is the name of the pharmacy that you normally go to? (Name/Location: anticipate more than one)
- May we call your pharmacy to clarify your medications if needed?
Over the Counter (OTCs) Medications
- Are there any medications that you are taking that you do not need a prescription for? (Do you take anything that you would buy without a doctorʼs prescription?) Give example, e.g. Aspirin. If yes, how do you take ________?
Vitamins/Minerals/Supplements
- Do you take any vitamins (e.g. multivitamin)? If yes, how do you take __?
- Do you take any minerals (e.g. calcium, iron)? If yes, how do you take __?
- Do you use any supplements (e.g. glucosamine, St. Johnʼs Wort)? If yes, how do you take them __ ?
Eye/Ear/Nose Drops
- Do you use any eye drops? If yes, what are the names and how many drops do you use and how often? In which eye?
- Do you use any ear or nose drops/nose sprays? If yes, how do you use them?
Inhalers /Patches/Creams/Ointments/Injectables/Samples
- Do you use any inhalers? any medicated patches? medicated creams or ointments? any injectable medications (e.g. insulin)? For each, if yes, how do you take ___? (name, strength, how often)
- Did your doctor give you any medication samples to try in the last few months?
Antibiotics
- Have you used any antibiotics in the past 3 months?
Closing
- This concludes our interview. Thank you for your time. Do you have any questions?
- If you remember anything after our discussion please contact me to update the information?
Exit room and wash hands. Proceed to document interaction in chart/file.
