PHARM29 Take a medication history


This standard describes the skills, knowledge and understanding necessary to identify the prescribed and/or purchased medicines and other substances taken by an individual. The competence can be applied in a variety of settings in hospitals and community settings including GP practices. 

Users of this standard will need to ensure that practice reflects up to date information and policies.

Version No 1

Knowledge and Understanding

You will need to know and understand:

  1. the basic principles of medicines management
  2. relevant national and local guidelines, policies, procedures that are available   including:
    1. when they should be used
    2. how to use them
  3. how medicines work on the human body and their actions
  4. the routes of administering medicines
  5. the different classifications of medicines
  6. medicines including:
    1. dosing
    2. adverse effects
    3. common drug-drug interactions
    4. common drug-food interactions
    5. common drug-disease interactions
    6. cautions and contra-indications               
  7. the factors which affect the storage of medication including expiry dates
  8. issues that may affect how medicines are taken including:
    1. problems with reading
    2. swallowing difficulties
    3. dexterity problems
    4. personal beliefs about taking medicines
  9. legislation and legal processes relating to valid consent
  10. the actions to take if valid consent is not obtained
  11. the importance of involving individuals in taking responsibility and how this can be achieved
  12. how to create a suitable environment for an open  and confidential discussion
  13. the importance of encouraging individuals to ask questions
  14. the importance of obtaining full and accurate information about individuals and how this can be achieved appropriate to their need
  15. the need to work in accordance with Standard Operating Procedures
  16. the limitations of your scope of practice and when to refer to others
  17. organisational policies, professional standards and confidentiality
  18. when and why Patient Medication Records (PMRs) are used
  19. the importance of maintaining accurate patient  records which may be
    1. written
    2. electronic
  20. the importance of maintaining confidentiality of an individual and their medication records

Performance Criteria

You must be able to do the following:

  1. ensure that you work in accordance with the Standard Operating Procedures at all times
  2. comply with legal, professional and organisational requirements and guidelines at all times
  3. ensure that the environment is suitable for open and confidential discussion with the individual or their carer about their medicines
  4. ensure that all reasonable steps have been taken to minimise any health and safety risks in the environment prior to commencing a discussion with the individual or their carer
  5. obtain valid consent from the individual or their carer in accordance with Standard Operating Procedures
  6. communicate with the individual or their carer in an appropriate manner and encourage them to seek information and advice as necessary
  7. adapt your communication style according to the communication needs of the individual
  8. encourage full participation in the assessment by actively listening to the individual, seeking to develop rapport and encouraging the individual to ask questions
  9. obtain personal details from the individual, their carer or appropriate sources
  10. identify the medicines and other substances and ascertain from appropriate sources when and how they are taken by the individual
  11. obtain appropriate information from the individual or their carer about their medicines
  12. use appropriate sources to identify details of medicines and other substances that have been
    1. started recently
    2. stopped
    3. changed
    4. used regularly
    5. used occasionally
    6. swapped or shared between individuals or their family and friends
  13. ask the individual or their carer if they have experienced any problems or difficulties with their medication
  14. report any problems or adverse reactions that the individual may have experienced from their medication in line with Standard Operating Procedures
  15. establish how  the individual is taking their medicines and why
  16. maintain clear, accurate and legible records in accordance with Standard Operating Procedures, organisational policies and within the scope of your responsibility and practice
  17. convey information obtained from the individual or their carer to an appropriate person and record outcomes in accordance with Standard Operating Procedures

Additional Information

This National Occupational Standard was developed by Skills for Health.

This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004):

Dimension: HWB6 Assessment and treatment planning
PHARM29 Take a medication history
Final version approved June 2010 © copyright Skills For Health
For competence management tools visit tools.skillsforhealth.org.uk