Obtaining an Accurate Medication History

Healthcare Training Resource
May 14, 2012 — 1,371 views  
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A patient's medication history will determine, in part, the treatment that medical professionals are able to give him or her. Additionally, healthcare professionals in the insurance market often need medication histories to help patients choose coverage options and to assign rates. Getting an accurate medication history from a patient, however, can be challenging. Patients -- because they are not healthcare professionals -- often have a limited understanding of their own medication history. To reduce medication errors, healthcare professionals can develop specific medication history recording procedures and use electronic histories.

Using Specific Medication History Recording Procedures

Each organization within the healthcare industry must have a specific set of procedures designed for obtaining medication history. That procedure should not be based on a single method of obtaining the medication history. In other words, healthcare professionals should not just obtain an oral medication history from the patient. Instead, professionals should locate medication history documents from previous doctors of pharmacies. However, they should also have the patient fill out a medication history form. Any discrepancies in the histories should be discussed with the patient and previous healthcare professionals who treated him or her.

In addition to creating specific medication history recording procedures that use various methods of data collection, healthcare professionals should also enlist a point person or team to collect the medication history data. This lessens the chance that personal information is not misplaced and individuals' data is not confused due to human error.

Finally, the specific methods of medication history reporting should include a procedure for organizing, storing, and sharing the data that is obtained. This will help to reduce medication errors by making it harder for patients' records to be purposely or accidentally altered.

Using Electronic Histories

More and more hospitals are choosing electronic means of obtaining medical histories as a way to reduce medication error. Electronic medication histories are stored on computers, so they are easy to access and read. It is easy for hospitals or doctor's offices to cross-reference the electronic medical histories with histories at other healthcare organizations. Not only does this make accuracy much easier to obtain, but it also makes errors much more difficult because hospitals can trigger alerts that will go off if a patient is about to be given an incorrect dose of medicine.

Obtaining an accurate medication history can help doctors and other healthcare professionals reduce medication errors, saving lives.

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