How to take medical history as a pharmacist

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Medical history taking is a crucial part of patient care, and as a pharmacist, it's essential to have a comprehensive understanding of how to take a medical history. In this video, we'll cover step by step instructions on how to take a medical history as a pharmacist, including what questions to ask and how to document the information gathered.

Step 1: Introduce yourself and explain the purpose of the medical history. Start by introducing yourself and explaining that you'll be taking the patient's medical history. It's essential to communicate to the patient that you're gathering this information to provide them with the best possible care.

Step 2: Gather demographic information. Begin by asking the patient for their name, age, gender, and contact information. This information will help you identify the patient and contact them if necessary.

Step 3: Ask about the chief complaint. The chief complaint is the primary reason the patient is seeking medical care. Ask the patient about the specific symptoms they're experiencing and how long they've been experiencing them.

Step 4: Ask about medical history. Ask the patient about their past medical history, including any medical conditions they've been diagnosed with, surgeries they've had, and any hospitalizations they've had. It's also essential to ask about any medications the patient is currently taking, including prescription and over-the-counter medications.

Step 5: Ask about family history. Inquire about any medical conditions that run in the patient's family, such as heart disease, cancer, or diabetes. Family history can provide insight into potential health risks for the patient.

Step 6: Ask about social history. It's crucial to ask about the patient's social history, including their occupation, living situation, and any hobbies or activities they participate in regularly. You should also ask about their tobacco, alcohol, and drug use.

Step 7: Review systems. Review systems involve asking the patient about symptoms related to each organ system. This process helps to identify any potential underlying medical issues. Ask about the respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, neurological, and endocrine systems.

Step 8: Document the information gathered. It's essential to document all of the information gathered during the medical history-taking process accurately. This documentation should be detailed and include all of the patient's demographic information, chief complaint, medical history, family history, social history, and review of systems.

In conclusion, taking a medical history as a pharmacist is a crucial step in patient care. By following these step-by-step instructions, you can gather the necessary information to provide the patient with the best possible care. Remember to communicate effectively with the patient, ask comprehensive questions, and document all of the information gathered accurately.













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