Medication History Documentation Practice Question

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Carley Castelein
Carley Castelein's picture
Last seen: 2 days 23 hours ago
Joined: 07/28/2019 - 10:57
Medication History Documentation Practice Question

We are trying to review our medication history collection process to make it as robust as possible. The question I have for the group is, do you have the medication history collector (RN, pharmacy tech, other) document what the patient is actually taking on admission or what they are supposed to be taking?

Here are a few scenarios we are thinking through when we teach staff the best process and are struggling to provide clear guidance on what to document as active home med for instances like these.

a. Patient stopped taking augmentin yesterday on day 2 of 7 day course.
b. Patient is prescribed glipizide 5mg daily but is only taking 2.5mg to make their supply last longer.
c. Patient has rivaroxaban in system on home med list from their last visit with indication of AFib, the patient says "I stopped taking that 3 weeks ago, it doesn't make me feel better."

Any policy/procedure/education verbiage that is clear to provide guidance in these type of instances would be helpful because you can't teach/cover every type of encounter they will have.