ADA’s PharmaAdvice – Documenting your patients’ medications

This article first appeared in the June 2022 issue of the ADA’s News Bulletin.

A core competency for a safe prescriber is the ability to document a patient’s medication history accurately. Ensuring the patient’s medicines, drug allergies and adverse reactions are accurately documented is critical to accurate patient assessment, care planning and safe prescribing. It is even more important with elderly patients who often have long and complicated medical histories involving multiple medical conditions and polypharmacy.

Unfortunately, many dentists rely solely on GP medicine lists, even when they are months or years old, or on the patient’s recollection of their medicines from memory, both of which can be wildly inaccurate. The inadequacies of these methods become all too clear when you are facing a complaint.

I have just completed an expert opinion for yet another dentolegal case where the harm involved was related to the patient’s medicines. Throughout the case, a recurring problem was the poor documentation of the patient’s medication, not just by the dentists involved but the patient’s GP as well. The lack of documentation made it difficult to assign causality to the case and for the dentists to defend themselves.

A problem everywhere

It’s challenging for all health institutions to document patient medications, so this is not a problem specific to dentistry. It is a constant issue in hospital emergency departments (ED) where patient presentations are unplanned and, in the heat of the moment, no one thinks to bring their medication with them. Studies have shown that if a medication history is based solely on patient interview, up to 67% of medication histories contain at least one error. (1) Inaccurate medication histories at the time of hospital admission cause at least 27% of prescribing errors in hospital. (2) The most common error is omission of a regularly used medicine and 30% of these errors have the potential to cause patient harm.(3-5)

As a result, most hospitals employ a pharmacist in the ED to take responsibility for compiling a Best Possible Medication History (BPMH), not just by interviewing the patient, but also by contacting the patients’ doctor/s, pharmacy, carers, interrogating hospital discharge summaries, and inspecting the medications themselves.

To further address the problem, in 2014, the NSW Clinical Excellence Commission, published a Medication Reconciliation Toolkit aimed at upskilling all health professionals who are responsible for documenting medicines. The toolkit’s mission is to “reduce the unintentional changes to patients’ medicines at transfers of care, which can result in considerable harm and are linked to worse health outcomes, increased hospital readmissions and mortality.” (6)

What does a comprehensive medication history look like?

A comprehensive medication history is an accurate recording of a patient’s medicines and adverse reactions. It comprises a list of all current medicines including prescription and non-prescription medicines; oral and non-oral medicines; those taken regularly and as-required; complementary healthcare products; social and recreational drugs; recent changes to medicines; past history of adverse drug reactions including allergies. It is always important to double-check that medicines that don’t come as a pill are included, such as patches inhalers, eyedrops, injections, depots as these are often forgotten.

The checklist in Table 1 (below) from the CEC Toolkit (6) can be a useful tool for ensuring all types of medicines have been deliberately prompted and explored.

What to include

The medication list should not only document each medicine’s name but also the following:

– Both names of the drug if possible: generic and brand name;

– Drug formulation: tablets, capsules, patch, syrup, implant, etc;

– Route of administration: oral, sublingual, transdermal, IV, subcut, etc;

– Dose taken (strength and frequency): 5mg daily, 60mg every six months; and

– Duration of treatment: roughly how long they have been using that medicine.

A sample layout is given in Table 2.

Why include dose and duration?

I am often asked why it is necessary for dental practitioners to know the dose and duration of each medication. They say: ‘Surely all I need to know is the drug and whether the disease treated is well controlled or not’. Unfortunately, knowing just the drug names tells only a fraction of the story. The main reason why dose and duration are important is for assessment and calculation of adverse effects.

When assessing whether a drug could be the cause of ANY worrying symptom, the first step is to assess the timing of the adverse event and how well it coincides with the timing of drugs being used. Secondly, the drug’s dose is important as some adverse effects are dose-dependent and others are not.

For example, if a person is on Prednisone, recording just the drug’s name makes it impossible to determine whether the patient is at risk of corticosteroid side effects, particularly adrenal suppression. Once you are advised they have taken 10mg daily for five years, you know for sure they would have many corticosteroid side effects and definitely adrenal suppression, in which case they would require steroid cover for a prolonged dental procedure. However, if they say their dose is 50mg per day but only for three days and they’ll be stopping tomorrow, then they will have few side effects and no adrenal suppression whatsoever.

Another example is working out drug-induced taste disturbances. These usually have a rapid onset and are very dose dependent meaning the bigger the dose, the bigger the dysgeusia and vice versa. So if the patient claims their taste disturbance, which started one month ago, is drug-induced but the drug they wish to blame was started six months ago, then the drug is an unlikely culprit. We’d be looking for something to blame that fits the timing more closely.

Don’t forget drug allergies and adverse reactions

A medication history should conclude with enquiry about past allergies, adverse reactions and intolerances, asking open questions such as: ‘What side effects or allergic reactions have you experienced with medicines?’. As for the medicine list, it is preferable to document adverse reactions with plenty of detail. It is inadequate to simply write ‘Allergy – penicillin’ or ‘Ibuprofen – rash’ as this does not provide enough detail to support clinical decision making. Table 3 (on the next page) presents this information in three columns.

Give them space, give them time

It’s important to give patients plenty of space and time to complete their medication history. A table gives patients plenty of space and the columns prompt for the details required for each drug. Make sure you also give them time. Advise them when they make their appointment that they should bring an up-to-date list of all their medicines with them. Advance warning allows an opportunity to conscript the help of others such as carers, relatives, their GP or pharmacist. Most pharmacists love compiling a Medicines List; some may even conduct a medication review while they’re at it. A Medicare-funded service called a Medscheck may also pay for the pharmacist’s time. there are also many apps for patients to record their medicine list electronically on an ongoing basis.

So consider sending your patients a table like Table 2, prior to their appointment or have it on your website for them to complete. Once a comprehensive medication history has been compiled, consideration can be accurately given to whether the patient’s medicines have contributed to their presentation, and whether any new treatments can be safely added into the mix.

References

1 Tam V, Knowles SR, Cornish PL et al. Frequency, type, and clinical importance of medication history errors at admission to hospital: systematic review. CMAJ 2005; 173: 510-5.

2 Dobrzanski S, Hammond I, Khan G et al. The nature of hospital prescribing errors. Br J Clin Govern 2002; 7:187-93.

3 Cornish PL, Knowles, marchesano R et al. Unintended medication discrepancies at the time of hospital admission. Arch Int Med 2005; 165:424-9.

4 Vira T, Colquhoun M, Etchells EE. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care 2006; 15:122-6.

5 Gillespie, U., A. Alassaad, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: A randomized controlled trial. Archives of Internal Medicine 2009; 169(9): 894- 900.

6 Clinical Excellence Commission, 2014. Continuity of Medication Management: Medication Reconciliation Toolkit, December 2014. Sydney: Clinical Excellence Commission.