Medication Reconciliation
How to ask questions for a Medication History
1. Ask about all medications:
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Prescription
Over-the-counter
Anything from a herbalist or health store?
Herbs
Vitamins or supplements
Teas
Traditions remedies (from other countries?)
2. Include:
• name
• dosage form
• dose
• schedule
• last dose taken
Note: (be specific about prn medications)
Questions should be:
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3. Ask about recently started
medications, or dosage changes
Balance open-ended questions with
yes/no questions
Nonbiased questions
No leading questions
Vague responses may indicate nonadherence
Avoid medical jargon
Encourage questions from patient
Encourage bringing meds and use of
medication wallet card
Give out wallet cards
Prompt regarding non-pill dosage forms
and prns
Creams, drops, inhalers, spray, samples
Allergies: ask about symptoms
Use multiple sources of information:
o Medication labels
o Family
o Community pharmacy
o Family physician
Sample Questions for Medication History Interviews
1. Did the doctor change the dose or stop any of your medications recently?
2. Have you changed the dose or stopped any of your medications recently?
3. Have any of the medications been causing side effects?
4. Your profile indicates that you may have run out of some medications. Are you still taking any of these?
5. Have you spent any days in the hospital for the past year?
6. When you feel better, do you sometimes stop taking your medicine?
7. Sometimes if you feel worse when you take your medicine, do you stop taking it?
8. Have you changed your daily routine to accommodate your medication schedule?
The Safer Healthcare Now! (SHN) campaign offers Canadian healthcare organizations the opportunity to participate in and
support a campaign dedicated to improving patient safety, through the implementation of six targeted interventions in patient
care.
Institute for Safe Medication Practices Canada
L’Institut pour l’utilisation sécuritaire des médicaments du Canada