Patient drug history medical records

The medical record is another source of medication and health-related information. Access to this record may be limited in certain practice settings however, it can be a valuable tool to review prior to conducting your patient drug history interview. Some practitioners use medical release forms to obtain medical record information such as laboratory data from other institutions required for drug therapy monitoring. 

Evaluate the patient s medical record and medication history, and conduct a patient interview to assess for the presence of drug allergies, adverse drug reactions, and drug interactions. 

Access to a patient s medical records is essential to the provision of collaborative drug therapy management. In fact, it is only under these conditions, wherein the phamiacist has adequate knowledge of the patient and the patient s history, disease states, drug therapy, and laboratory and procedure results, that quality care can be rendered. Much work is being done in this area, via computerization of medical records and network facilitation of electronic data, to ensure this key element is in place to facilitate patient care by health care providers. 

The primary care provider also may order laboratory and di nostic tests, such as an electrocardiogram, renal and hepatic function tests, complete blood count, serum enzyme, and serum electrolytes. Th e tests should be reviewed before the first dose of the drugis given. Renal function is particularly important because a diminished renal function could affect the dos e of digoxin. When subsequent laboratory tests are ordered, they also should be reviewed when the results are recorded on the patient s record. Because digoxin reacts with many medications, the nurse must take a careful drug history. 

Allergic reactions to commonly used amide anesthetics are rare. To identify patients with true allergic reactions, a careful history should be recorded regarding prior anesthesia. Attention should be placed on the offending drug, route of administration, concurrent medications. 

Antimicrobial medication requires the nurse to follow the same general administration procedures that are required for any type of medication. The most critical step is to determine if the patient has allergies to drugs, food, environmental stimuM, and a family history of allergies to antibiotics. There is also a high incidence of cross sensitivity between some antibiotics such as penicillin and cephalasporins. Always display allergies in red and clearly write them on the patient s record. Even if the patient s record indicates that the patient doesn t have allergies, always ask the patient each time you administer the antimicrobial medication. 

Modern technology should help. For example, pharmacists are developing databases that help them to identify drug interactions. In the future, the medical history of a patient could be added to a card which could be used by a pharmacist to ensure that the patient s prescribed medicine is appropriate. It would also be possible to input safety data on drugs to computer systems already used by prescribing physicians to store their patients records. The physician would then be alerted to any contraindications, warnings or precautions that may be relevant to individual patients if prescribed the drug. 

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