Drug documentation and drug history taking

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Transcript Drug documentation and drug history taking

Drug documentation and drug
history taking
Allergies
Are you allergic to any drugs?
 What happened when you took this
medication?
 When was this reaction?
 Have you taken that medication since?
 Do you have any other allergies?

Drug history
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Are you taking any tablets or use any inhalers
at the moment?
What do you take that for?
How many times a day do you take your
medication?
How many do you take?
Do you know the strength of the tablets?
Do you buy medication from the chemist?
Do you take any other drugs( herbal or
recreational!)
35 year old obese woman.
 PMH: asthma.
 In bed for past few days with fever.
 Diagnosed with a chest infection and DVT.
 Her regular medication includes ventolin when she
wants & Becotide 50 mcg 2 puffs twice a day.
 She takes the oral contraceptive pill microgynon-30.
 Solpadol 2 tabs every 6 hours for back pain.
 She is allergic to penicillin.
 The registrar asks you to write up a loading dose of
wafarin 6mg.
 Microbiology recommends Erythromycin 500mg TDS
for her chest infection.
 The nursing staff ask you to prescribe lactulose,
paracetamol and night sedation.

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Total Directorate Med Errors Jan- Sept 04
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Contirbutory Factors For Prescribing Errors
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