2. Introduce yourself and tell them why you’re there and verify the identity of the patient.
3. Build rapport (Smile, make eye contact, find something in common to break the ice, active listening, touch when appropriate (shake hands).
4. Look at source of information (ie patient, spouse, translator – preferably NOT family member).
5. Ask patient if they brought their in their medications from home.
6. What to ask about prescription medications/supplements/OTCs? Name, strength, route directions, duration, compliance, efficacy “is it working for you?” and adverse effects.
7. Vaccine history (influenza, pneumoccoccal, shingles, DT, hepatitis B etc)?
8. Habits? (ie alcohol, tobacco, caffeine, recreational drugs etc) You have to worry about withdrawal in hospital! How to manage? (ie give patient nicotine patch, monitor for s/sxs of DTs etc).
9. Allergies to medications, food, preservatives, latex, pollens etc.?
10. Past medications? (inquire about any medication changes (ie Why was the strength increased? Was it too expensive?)
11. Look at patient's compliance/adherence (ie via blood levels, surrogate markers, etc).
12. Develop a plan based on medication history such as discontinuing a drug, reducing or increasing a dose, adding another drug, recommending monitoring paramenters etc.
Posted by: Stephanie Shieh