Knowby eHealth
Knowby
Best possible medication history guide
This is a Just in Time resource to support the mental model required to elicit a best possible medication history.
This is a Just in Time resource to support the mental model required to elicit a best possible medication history.
1
Step 1 of 12
<h1>Anchor the baseline</h1><h1></h1><p>Are you clear what the person was <strong>using as their usual baseline</strong>, separate from any changes made during this admission?</p><p></p>

Anchor the baseline

Are you clear what the person was using as their usual baseline, separate from any changes made during this admission?

2
Step 2 of 12
<h1>Start with the person’s story, not the system</h1><p></p><p>Have you heard the person’s version <strong>before</strong> looking at records?</p><p></p>

Start with the person’s story, not the system

Have you heard the person’s version before looking at records?

3
Step 3 of 12
<h1>Lock in a structure</h1><p></p><p>Have medicines been organised by <strong>routine</strong> (time, context, pattern)?</p><p></p>

Lock in a structure

Have medicines been organised by routine (time, context, pattern)?

4
Step 4 of 12
<h1>Flag PRN language</h1><p></p><p>Did you hear “sometimes”, “only when”, or “if needed”?<br></p>

Flag PRN language

Did you hear “sometimes”, “only when”, or “if needed”?

5
Step 5 of 12
<h1>Ground PRN in behaviour</h1><p></p><p>Do you know <strong>how it’s used</strong>, <strong>when it was last taken</strong>, and <strong>the usual pattern</strong>?</p>

Ground PRN in behaviour

Do you know how it’s used, when it was last taken, and the usual pattern?

6
Step 6 of 12
<h1>Sweep for common omissions</h1><p></p><p>Have non-tablet (inhalers, creams, patches, injections) and "natural" supplements and medicines been explicitly considered?</p><p></p>

Sweep for common omissions

Have non-tablet (inhalers, creams, patches, injections) and "natural" supplements and medicines been explicitly considered?

7
Step 7 of 12
<h1>Look for exceptions</h1><h1></h1><p>Is anything taken differently than prescribed or listed?</p><p></p>

Look for exceptions

Is anything taken differently than prescribed or listed?

8
Step 8 of 12
<h1>Check other evidence</h1><p></p><p>Have you compared the person’s account with the <strong>best available evidence</strong> (e.g. medicine packs, pharmacy history, prior summaries, system records)?</p><p></p>

Check other evidence

Have you compared the person’s account with the best available evidence (e.g. medicine packs, pharmacy history, prior summaries, system records)?

9
Step 9 of 12
<h1>Resolve or label uncertainty</h1><h1></h1><p>For each medicine, is it either <strong>confirmed</strong> or clearly marked as <strong>uncertain / needing follow-up</strong>? </p>

Resolve or label uncertainty

For each medicine, is it either confirmed or clearly marked as uncertain / needing follow-up?

10
Step 10 of 12
<h1>Clarify timelines</h1><p></p><p>Is it clear what was:</p><ul><li><p>used before admission</p></li><li><p>changed during admission</p></li><li><p> prescribed to continue upon discharge?</p></li></ul><p></p>

Clarify timelines

Is it clear what was:

  • used before admission

  • changed during admission

  • prescribed to continue upon discharge?

11
Step 11 of 12
<h1>Record for handover</h1><p></p><p>Could another clinician understand <strong>what you know, what you don’t, and why</strong>?</p>

Record for handover

Could another clinician understand what you know, what you don’t, and why?

12
Step 12 of 12
<h1>Triage risk</h1><p></p><p>Are high-risk medicines resolved or clearly escalated?</p><p></p>

Triage risk

Are high-risk medicines resolved or clearly escalated?