List of All Medications

Intent:

To facilitate a medication evaluation by having a single listing of all prescribed and non-prescribed medications taken by the person.  This section will assist clinicians identify potential problems related to the consumption of, or failure to take, medications (e.g., potential physical or emotional problems a individual may experience as the result of taking one or more medications.)  For example, identifying the frequency an individual uses a PRN (as needed) pain medication, sleeping medication, or laxative may lead the clinician to do further assessment related to underlying problems that prompted their use.  It may also help the clinician to identify medications that might cause specific problems such as incontinence or delirium.  

Definition:

Medications - include all prescribed, non-prescribed, and over-the-counter medications that the person consumed in the last 3 days.

Medications may be taken by mouth, placed on the skin or in the eyes, injected, given intravenously, etc.  This includes prescriptions now discontinued but taken in the last three days and drugs prescribed “PRN” – on need – that were taken during this period.  It also includes medications that are prescribed on a maintenance schedule, such as vitamin injections given once a month, even if they were not given in the last three days.

Process:

Ask the person, and family members when appropriate, to list all medications actually taken in the last 3 days.  Be certain that you specify that this is not just prescription medication, but any medication consumed regardless of how it was obtained.

Ask the person or family member to get out all the medications they are currently using or have used in the last 3 days.  It will help to have the actual drug container, so you can get the proper spelling of the drug name and accurate dosage and frequency.  If the person cannot actually get the medications out on their own, offer to retrieve them.  While you are documenting the medications for the assessment, review the schedule of medications with the person to verify when and how often they take each medication. However, be sure to tell the person that you need to know about all medications they have taken (prescription and others), regardless of how they were obtained.  In some cases, it may be possible to get a print-out from the person's pharmacy of all current drug prescriptions.  If so, make sure: a) the list is current; b) the person is actually taking each prescription, especially those listed as “PRN”(as needed); and c) the person gets their drugs only from this pharmacy. In addition, ask the person if they (or someone on their behalf) visited the drug store to get any over-the-counter medications. Ask if the person is taking any specific drugs for problem conditions they may have mentioned to you (e.g., constipation, allergies, skin rashes or fungus infections).  They may also have visited a doctor in the past few days, in which case you can ask whether any of their medications were changed.  If so, note which ones were added or discontinued.

In recording the information on the form or in the computer, be sure to recheck the list of medications twice, so that you do not miss any. Make sure you count medications that may have been discontinued, but were administered in the last three days.

NOTE: Herbal preparations in all forms (pills, liquids, powders, teas, etc.) should NOT be included in, List of all medications.  According to the U.S. Federal Drug Administration, herbal preparations are considered nutritional supplements and not medications.

The coding instructions are extensive. Review them carefully. Study the examples. Complete the coding exercises at the end of this section.

Coding:

Record all medications that the person received (actually swallowed, inhaled, injected, or applied to skin, eyes, etc.) in the last three days. Also record any prescribed medications that may not have been consumed in the last three days, but are part of the person’s regular medication regimen (e.g. monthly B-12 injections).

Count only those PRN (as needed) medications that were actually taken by the person in the last 3 days.

Record the name of the medication and dose that was ordered by the physician in column 1. Write the name of the medication and dose EXACTLY as it appears on the medication container. For example, if the medication label indicates Acetaminophen 650 mg, do not write Acetaminophen 325 mg. 2 tabs — even if two 325 mg. tables were actually taken by the person.

Occasionally, dosages of medication may have changed during the 3-day assessment period. In this case, each dosage of the medication should be recorded separately

Example

Medication list obtained by reviewing all the person’s medications with them (for assessment period of 8/14/2005-8/16/2005)

A. Ampicillin 250 mg. every six hours for  10 days, by mouth. (8/10-8/16)

B. Beconase nasal inhaler 1 puff  twice a day

C. Compazine suppository 5 mg. as needed for nausea (taken on 8/15/05)

D. Lanoxin 0.25 mg.  every other day, by mouth. On alternate days, take  Lanoxin 0.125 mg.

E. Peri-colace 2 capsules at bedtime, by mouth .

F. Humulin N 15 Units before breakfast daily  SQ

Check blood sugar daily at 4 p.m. Sliding scale insulin: Humulin R5 units if blood sugar 200-300; 10 units if over 300. (5 units given on 8/14/2005 for Blood Sugar of 255; 10 units given on 8/16/2003 for Blood Sugar of 305)

G.  (Over-the-counter) Claritin one tablet (10 mg.) each day, taken three times in the last three days