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December 2, 2017












How to take a medication history in optometry and WHY

By Dr Geraldine Moses DClinPharm


Dr Geraldine Moses BPharm DClinPharm AdvPracPharm FPS FACP AACPA MSHP MRPharmS

Consultant Pharmacist to the Australian Dental Association

Consultant Clinical Pharmacist- Mater Health Services, Brisbane

Adjunct Assoc Professor- School of Pharmacy- University of Queensland



We all know that a documenting patient’s medication is an important part of taking a medical history, but not many of us have been taught how to do it properly.


So how can optometrists do a better job at documenting patient medications without spending too much time on it, of course.

Currently, most people just write down whatever they can while the patient tries to remember what they take or fumbles with a scratchy piece of paper from their wallet. 


“I know I take a white one” is a common refrain.


When reviewing medication profiles taken by other health professionals I often see that drug names ONLY are documented: 


For example: 

“Patient takes aspirin, metoprolol and glucosamine”


This is inadequate as knowing the drug names is only part of the story.


Look at the huge difference between knowing a person is just on prednisone, versus 50mg prednisone daily for three days versus 5mg prednisone for three years.


Adding the dose and duration makes all the difference.

In pharmacy, we have turned medication history-taking into an art form. We pride ourselves in creating what is called a Best Possible Medication History or ‘BPMH’ for short, which takes about an hour and half to complete. A BPMH is most often required for hospitalised patients who arrive for unplanned admissions with no information about their medication. But frankly, everyone could do with a BPMH.


A Best Possible Medication History is defined by the ACSQHC as:

“An accurate recording of a patient’s medicines. It comprises a list of all current medicines including prescription and non-prescription medicines, complementary healthcare products and medicines used intermittently; recent changes to medicines; past history of adverse drug reactions including allergies; and recreational drug use”.


I am not asking you to become pharmacist or even to take a BPMH, although there’s no harm in trying!


Obviously there isn’t sufficient time in a busy optometry practice to spend all day delving into people’s medications. 

Here are the essential details that should ideally be documented:


1. THREE THINGS for each drug

For each medicine THREE things should be specified -

DRUG NAME, DOSAGE, and DURATION of treatment.


To document this it helps to use a table that is divided into three columns (+/-a fourth for notes) as this will automatically prompt you and/or the patient for the necessary information.


Asking patients to complete this form before their appointment can be most efficient and accurate, as they won’t have to rely on memory and can ask their pharmacist or doctor for assistance,


Start by asking about prescription drugs,  but once completed, move onto non-prescription medicines including those purchased in a pharmacy, supermarket, health shop, from a naturopath or on-line.  



Repeat the above for non-oral medication, including, eyedrops, ear drops, inhalers and puffers, injections, implants, and dermatologicals.



The above usually refers to medicines used regularly, so now ask about medicines that are used when required or “prn”. These are usually for symptom relief so focus on medicines used for dry eyes, pain, gastric reflux, sleep etc.



Alcohol, caffeine, marijuana and tobacco smoking fit in here, as their consumption should be quantified. Recreational drugs and lifestyle medicines such as those for hair loss or erectile dysfunction may occasionally impact on the patient’s diagnosis, so need to be adequately documented.



Since recently-used medicines can alter the presentation of some symptoms it can be very informative to know if the patient has recently taken or just finished antibiotics or other type of medicine.  This is where it should be documented.



Just in case it is relevant this is useful to know, as it is not uncommon for friends, family and spouses to share their medicines!


Now at this point you might be thinking “I prefer to get my patients to just bring in a list from their GP”.


That’s a good place to start, but a GP list is never comprehensive as it usually only documents that particular GP’s prescribing, it won’t include medicines from other doctors, non-medical professionals, non-prescription or complementary medicines.


I’m sure you can see now that, once all this information is collated, you will have an extremely good idea of the medication and other pharmacological substances your patient uses in their daily life.


Not only is this is a more appropriate basis on which to make health care decisions, but you also find out:

  • how they use their medicines,

  • their attitudes and beliefs towards medication and

  • whether they are likely to adhere to treatment - which can provide useful insight into treatment planning.




For more information on this article please contact us masterclasshelp@gmail.com

This information is provided to be general in nature only and may not be appropriate for all circumstances.