Ross: Prescribing

at a Glance

Sarah Ross

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?

    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.

    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?

    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

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