A best possible medication history (BPMH) is a history created using:
- A systematic process of interviewing the patient/family
- A review of at least one other reliable source of information to obtain and verify all of a patient's medication use (prescribed and non-prescribed)
Complete documentation includes drug name, dosage, route, and frequency. The BPMH is more comprehensive than a routine primary medication history, which is often a quick preliminary medication history that may not include multiple sources of information. It is a snapshot of the patient's actual medication use, which may be different from what is contained in his or her records. This is why patient involvement is vital!
Who Should Obtain the BPMH?
The person collecting the BPMH should be a healthcare professional (e.g., doctor, nurse, nurse practitioner, pharmacist) whose scope of practice includes this activity and who:
- Is trained in creating a BPMH
- Follows a systematic process, such as a BPMH interview guide, where possible
- Is conscientious, responsible, and accountable for conducting the medication history process
The task of collecting the BPMH may be delegated to other healthcare providers (e.g., pharmacy technicians) if the organization maintains a training and quality assurance program to support this activity.