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Drug documentation and drug history taking

Allergies
Are you allergic to any drugs? What happened when you took this medication? When was this reaction? Have you taken that medication since? Do you have any other allergies?

Drug history

Are you taking any tablets or use any inhalers at the moment? What do you take that for? How many times a day do you take your medication? How many do you take? Do you know the strength of the tablets? Do you buy medication from the chemist? Do you take any other drugs( herbal or recreational!)

35 year old obese woman. PMH: asthma. In bed for past few days with fever. Diagnosed with a chest infection and DVT. Her regular medication includes ventolin when she wants & Becotide 50 mcg 2 puffs twice a day. She takes the oral contraceptive pill microgynon-30. Solpadol 2 tabs every 6 hours for back pain. She is allergic to penicillin. The registrar asks you to write up a loading dose of wafarin 6mg. Microbiology recommends Erythromycin 500mg TDS for her chest infection. The nursing staff ask you to prescribe lactulose, paracetamol and night sedation.

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Prescribing Errors - Drug

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