Many patients take multiple medications, prescribed by multiple professionals, in multiple settings. Often information about medicines is poorly transferred, therefore a structured approach to the patient’s medication history should be taken.
This guide can be used in two ways; to enhance any history that includes a drug history (including in an OSCE) or specifically by professionals wanting to focus on collecting a detailed drug history, such as pharmacists and pharmacy technicians or doctors and nurses during medication review consultations.
Start by asking if the patient has any concerns about their medication?
If the patient does have concerns, try not to address them straight away, as without knowing the patient’s full pharmaceutical history you can not really know how complicated their concern may be. If the patient has a concern, say something like “we can come back to that once we know a little bit more about your medication history.”
“Hello, my name is Adam and I’m the pharmacist working on the ward today.”
“Can I confirm your name is [Mary Smith] and your date of birth is [12th July 1958]”
“I’d like to ask you some questions about your medication. Is that okay?”
“Before we start, do you have any concerns about your medication that you’d like to bring up?”
“We can come back to that issue once we know a little bit more about your medication history.”
Currently prescribed medication
This section forms the basis of the history. There are six key bits of information you need to obtain about medication the patient is taking – the super six.
1. What is it? (drug name or characteristics)
This seems like a pretty obvious one but you’ll be surprised how often it gets missed. The pronunciation of drug names varies greatly so you may need to think outside the box when the patient tells you they’re taking a product that you’ve never heard of. Patients might also describe their medication based on colour, size, the shape of the actual formulation or the container (e.g. “The little red ones that come in the big green box”).
2. What is it for? (indication)
Many drugs have multiple indications and the most common indication may not be the reason the patient is taking the medication. Indications also change with time as products come in and out of fashion. For example, at one time, pregabalin was prescribed only to treat epilepsy, whereas now it is prescribed for neuropathic pain and generalised anxiety disorder. Medications can provide important collateral information for the medical history. The patient may not mention that they have pain or anxiety in their medical history but if they’re taking medication for it, then they probably have a diagnosis that may have been missed, so it is important not to make assumptions about what the drug is being used for.
3. How much (or how many)?
When asking patients for information about their medication, it is important to remember they may not think about doses in terms of milligrams or micrograms but rather one or two tablets, spoonfuls, capsules, puffs etc. It can be worth asking how ‘strong’ the medication is as sometimes patients will describe the dose of their medications this way.
4. How often?
This question provides two useful bits of information. Firstly it provides you with information about the full dosing regimen by providing the frequency (e.g. the patient takes one pink capsule three times a day). It also provides some information about the patient’s adherence to their treatment. In response to this question, the patient may say ‘now and again’ or ‘every day’ and this can help you identify if their presenting complaint may be due to medication non-adherence, including over and under-use.
5. Since when?
Knowing how long the patient has been taking a medication is important, as this changes the likelihood of risks such as Type A pharmacokinetic effects (e.g. diarrhoea, hypoglycaemia, hypokalaemia), Type B pharmacodynamic effects (e.g. anaphylaxis, blood dyscrasias) or Type C statistical effects (e.g. typically only seen at cohort level when patients have been using medication for a long period of time e.g. gastric ulceration with NSAIDs).
6. How do you take it?
Medication can behave differently depending on how it is taken. For example, medication that is taken with food is absorbed more slowly than medication taken on an empty stomach. Another example is a medication that is taken with milk (or close to breakfast) can chelate and not be absorbed at all, so it is important to find out how the patient takes the medication. This question should also help you identify if the patient is using a multiple-compartment compliance aid (‘MCCA’, aka a dosette box, tray, NOMAD, pill box) which, if not identified, can significantly delay discharge from hospital. This question will also help you to clarify what formulation the medication is (e.g. liquid, capsules, inhaler or subcutaneously injected etc). This is important to know as it may influence further investigations you may wish to do, such as to explore the patient’s inhaler technique.
After gathering this information you should summarise your findings to the patient to double check you have got the correct information.
You should ask the super six about each and every medication that is prescribed for the patient. You may notice that some patients will start to readily volunteer the information as they predict which question is coming next. Make sure to give the patient plenty of time to answer and try not to interrupt them.
“I’d like to start by finding out what medications you are prescribed by your GP or any specialists that you see and dispensed by a pharmacy?”
1. What is it? What do you call the medication you take?
2. What is it for? Why do you take that one?
3. How much (or how many)? How much of that do you take?
4. How often? How often do you take that? Is that [x] times a day regularly or just now and then?
5. Since when? How long have you been taking that?
6. How do you take it? On a typical day, how would you take that one? With food, or on an empty stomach?
“Okay, just to summarise, you take [pregabalin] for [anxiety], [one capsule] [three times a day]. You have been on it for [6 years] and you take it [regularly, on an empty stomach]. Is that right?”
*Repeat for each prescribed medication*
“Okay, thank you.”
After asking about prescribed medications, it’s important to check that the patient doesn’t take anything else that is not prescribed that they purchase over-the-counter or, increasingly, from the internet for self-care.
This could include supplements, vitamins, and herbal or homoeopathic remedies.
This is an important part of the drug taking history, as many of these products will influence the pharmacodynamic and pharmacokinetic properties of prescribed medication. For example, St John’s Wort can increase the metabolism and therefore reduce the efficacy of oral contraceptives.
It is important to ask the patient where they source their non-prescribed medications. If the products are purchased from a pharmacy, it is likely the product is high-quality and is what it says it is. However, if purchased online or from overseas, then the patient may be using a poor quality product. If this is the case, you should ask to see the product and ask the senior pharmacy team for support, particularly if the pathology of the presenting complaint is unclear.
“Do you take anything that you buy from a supermarket or over the internet?”
If yes, use the super six to find out more information about those products followed by:
“Where do you get that from?”
When asking about prescribed and non-prescribed medication, patients often forget to mention products that they may not classify as medications, such as eye drops, inhalers, sprays, patches or creams. However, many of these products contain pharmacologically active ingredients that can cause or exacerbate medical conditions.
“Do you take any eye drops, ear drops, inhalers, sprays, patches, injections, creams or ointments?”
When asking about extra medications, it can be helpful to point to your eyes, ears, mimic using an inhaler or spray, applying a patch to the top of your arm, or applying a cream. This isn’t evidence-based but it can trigger the patient’s memory (and can be entertaining to watch).
If the patient says they take any of those, use the super six to obtain a thorough history.
Social pharmacy history
A patient’s socialhistory can provide useful information when reviewing their pharmaceutical care. For example, smoking tobacco induces enzymes that speed up the metabolism of theophylline and changes in vitamin K consumption can reduce the efficacy of warfarin. Asking about a patient’s social history also facilitates asking questions about any recreational drug use such as cannabis or ecstasy.
Asking questions about the patient’s lifestyle will also provide collateral information about their treatment adherence. For example, someone who leaves at 5 am for a 90-minute commute to work is unlikely to want to take their Furosemide first thing in the morning. Additionally finding out if the patient has any support at home to take their medications may influence future prescribing decisions.
This is also a good opportunity to ask about any sideeffects or allergies the patient may have to any medication.
“I’m going to ask you some questions about your lifestyle now, is that okay?”
“Talk me through a typical day, from when you wake up to when you go to bed and how your medications fit into that?”
Listencarefully to the patient’s response. Use the questions below to help clarify any missing information.
“Do you work?”
“What do you work as?”
Support at home
“Do you have any help with your medications at home?”
“Is this from carers or your family?”
“Do you smoke any tobacco?”
“Do you drink any alcohol?”
Recreational drug use
“Do you use any recreational drugs, like cannabis?”
Diet and exercise
“What do you usually eat?”
“Do you do any exercise?”
“What types of exercise do you do?”
“Have you ever had any side effects to any medications?”
“Do you have any allergies to medications?”
Identifying the pharmaceutical care issue
At this stage of the consultation, you should revisit any concerns the patient may have had about their current medication regime. It’s also important to give the patient the opportunity to raise any additional concerns about their medication.
If you have identified your own concerns about the patient’s medication regimen, for example, if the medication is not being used correctly, you should raise them for discussion with the patient in this part of the consultation. The patient will be able to offer you their perspective and you can negotiate the best way to address these concerns.
If a patient is unwilling to change the way they use a medication and you feel that they’re at high risk of significant harm then you can say something like “I’m going to have to stop that medication because…”
“You mentioned you were concerned about …. is there anything else you’re concerned about?”
“Something I’m concerned about in relation to your medication is that ….”
“You mentioned that you take your ibuprofen without food?”
“You mentioned that you miss your insulin now and again?”
“You mentioned that you crush your modified-release carbamazepine?”
“I’m concerned about this because….”
“When you take ibuprofen that way it can upset your tummy and cause ulcers.”
“When you miss insulin it can cause problems for your diabetes.”
“When you crush your carbamazepine it may not work as effectively as it should.”
“Would you be interested in changing the way you use that medication?”
Propose an acute plan of action
The actionplan will depend greatly on the patient’s perspective. They may be unwilling to change too many medications at once because it will disrupt their routine or they may be fearful that their condition might get worse.
Pharmaceutical management plans may include any of the following points:
No changes to the current regime
Withhold a medication temporarily
Additional therapy to deal with a side effect (e.g. adding a laxative following opioid-induced constipation)
Referral to a specialist pharmacist, medical consultant, GP or nurse if you have reached your level of competence and require additional input
Plans should include short-term and long-term outcomes.
Who will do what?
Over how long?
Any monitoring required?
Who will do what?
Over how long?
Any monitoring required?
“Okay, so in the short–term, we would like to reduce your dose of diazepam as you feel like it is making you too drowsy.”
“Let’s change your dose from tomorrow so you take 5mg less.”
So for the next two weeks, you will only take one diazepam tablet each day.”
“I will give you a call in two weeks to see how you’re getting on. Is that okay?”
“In the long-term, I think the rest of your medication is okay.”
“We can ask the GP to review everything again in six months.”
“I don’t think we need any additional monitoring or tests done at this point for anything. Is that okay?”
When closingtheconsultation it’s a good idea to summarise as much as you can, including the information on the currently prescribed medication, the non-prescribed and the extras to make sure nothing has been missed. You should also summarise the short term and long term plan so the patient understands it fully and give the patient a final opportunity to ask any questions about what has been covered and anything that has not been covered.
“Okay, so we’ve discussed your medication which included [two inhalers, your medication for anxiety, pain, diabetes, epilepsy and headaches and the vitamins you buy over the counter]. The plan is to reduce your diazepam by one tablet each day and I’m going to call you in two weeks to see how you feel that is going and then review everything else again at your usual review appointment with the GP surgery.”
“Do you have any questions about what we’ve covered in this consultation?”
“Do you have any questions about anything we haven’t covered that I may be able to help with?”
“If you think of anything afterwards, my name is Adam and you can get in touch with me by asking the nurses to contact pharmacy/calling me on 1234 567 8912”
After the consultation
The patient is the most valuable source of information in relation to their medication – they’re the ones who ultimately take them. However, if possible, you should try and obtain a collateral history from another source to confirm the patient’s doses.
Some sources you may want to consider using include:
Summary Care Record
Patient’s copy of their repeat prescription
The actual products (some patients bring their medication to consultations or hospitals in a Green Bag which makes it much easier to check doses. Be wary that this medication is actually the patients and not their partner’s or pet’s.)
Care home medication administration record
Family members or carers
Following the consultation, you should try and record the information in the patient’s notes, including what sources you used. It may be possible to add this to the patient’s current prescribed medication if you’re using an electronic prescribing system or you may have to free-type or write out the information directly into the patient’s paper notes. This can be time-consuming but try not to rush – many significant patient safety incidents occur because medication-related information is transcribed incorrectly. Take your time and double check that what you have documented is what you intended.
If you’re free typing/handwriting in paper notes, try and include the super six pieces of information for each medication as a minimum as well as your short and long-term plan of action.
References / further reading
1. Abdel-Tawab R, James DH, Fichtinger A, Clatworthy J, Horne R, Davies G. Development and validation of the Medication-Related Consultation Framework (MRCF). Patient Education and Counseling. 2011;83:451-457.
2. Kurtz S, Silverman J, Benson J, Draper J. Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary–Cambridge Guides. Academic Medicine. 2003;78:802-809.
3. Centre of Pharmacy Postgraduate Education. Consultation skills for pharmacy practice: taking a patient-centred approach. University of Manchester: Manchester. 2014.
4. Nickless G, Davies R. How to take an accurate and detailed medication history. The Pharmaceutical Journal. 2016.
5. Krska J, Cromarty J, Arris F, Jamieson D, Hansford D. Providing pharmaceutical care using a systematic approach. The Pharmaceutical Journal. 2000;265:656 – 660.