Obtaining accurate medication history, including drug allergies and complementary and alternative medicines

Overview

Accurate medication history-taking requires systematic, structured enquiry covering prescribed medications, over-the-counter products, and complementary/alternative medicines - each category requiring specific prompting given patients' tendency not to volunteer non-prescription products unless directly and specifically asked
A foundational clinical skill underlying safe prescribing across all of medicine, with medication history inaccuracy/incompleteness a well-recognised, common source of preventable medication error, particularly at transitions of care

Patients commonly compartmentalise "medication" as meaning only prescribed pharmaceutical products, mentally excluding over-the-counter analgesics, vitamins, and herbal/complementary products from what they consider worth mentioning when asked generically "what medications are you on" - explaining why structured, specific enquiry naming these categories substantially improves disclosure completeness compared with an open-ended general question alone

Multiple information sources (patient/carer report, current medication packaging/list brought to appointment, pharmacy dispensing records, previous clinical records) should be cross-checked where possible, since any single source alone carries a meaningful risk of inaccuracy or omission
Specific enquiry should explicitly name categories often omitted from a generic question (over-the-counter analgesics, vitamins/supplements, herbal products, and any medications borrowed from family/friends)

A complete, accurate medication history should be established before prescribing any new medication with interaction potential, and specifically reconciled at every transition of care (admission, transfer, discharge) given the elevated error risk at these points
Discrepancies identified between sources should be actively clarified with the patient rather than assumed to reflect either source being definitively correct

Complementary/alternative medicine under-disclosure (a specific, common gap), medication reconciliation at care transitions, multiple-source cross-checking, borrowed/shared medication use (an under-recognised but clinically relevant scenario)

Asking a patient generically "what medications are you taking" reliably under-captures over-the-counter products, vitamins, and complementary/alternative medicines, since most patients don't mentally categorise these as "medications" worth mentioning - specific, structured enquiry naming these categories explicitly is necessary to obtain a genuinely complete medication history

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