Case Studies

Chapter 4: Taking a medication history

An 89-year-old woman is admitted to a medical ward with a urinary tract infection. She is unable to give a list of her current medication.

• 1. What is medicines reconciliation and why would it be helpful in this case?

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  Model answer: Medicines reconciliation is a process by which the most accurate list of a patient's current medicines is compiled.
  It has been shown to reduce errors in identifying a patient's medicines

• 2. List the sources of information which could be used as part of a medicines reconciliation process.

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  Model answer:
  The patient's family
  A dosette box if used
  Any medicines found in the patient's home
  Previous hospital discharge letters
  Community pharmacy records (particularly if the patient regularly uses the same pharmacy)
  GP prescribing information

• 3. Which types of non-prescription medicine might she be taking in addition to her prescribed medication, and how might these be identified?

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  Model answer: Over-the-counter medicines from the pharmacy such as simple analgesia Alternative medicines sourced from a pharmacy, health food store, over the internet Could be identified by family, from containers found in the patient's home, GP or hospital records where previously discussed