Put all three items on her medication list. The history must hold a complete list of prescription drugs and of anything bought without a prescription. That includes vitamins, minerals, and herbal supplements. Most patients do not count these as medicine. Women often leave out birth control pills for the same reason. So you ask about them by name. Her first answer was not a lie. It was only too narrow.
These products matter because they act on the body. Fish oil and some herbs can slow blood clotting. So does warfarin (Coumadin), a prescription blood thinner. The doctor must know that before eye surgery is booked. Birth control pills carry their own eye risks. A drug that is not in the chart cannot be checked by anyone. Writing down one pill hides two of them. Writing down nothing hides all three. The list is part of the permanent record, and you update it at every visit. Some herbs also change how other drugs work in the body. Aspirin thins the blood as well. Many people take it daily and never call it a drug.
Ask twice, and ask in plain words. Any pills, drops, vitamins, or herbs? gets a fuller answer than Any medications? Write what the patient truly takes, not what you think counts as a drug. Read the list back to her before you move on. For each item, note the purpose, the dose, and how long she has used it. If she cannot recall a name, ask her to bring the bottles next time. Also ask about allergies to drugs, pollen, and food in the same breath. A full drug and supplement list is a core skill in the COA history and documentation content area.
Incorrect Answers
- B. This keeps only the prescription item. The fish oil is the very product that can affect bleeding in surgery, so leaving it out is the worst of the three gaps. A short list still looks complete to the next reader.
- C. A blank list is a false record. The patient corrected herself, and the chart must show what she said last, not what she said first. A blank line also tells the surgeon there is nothing to weigh.
- D. Social history covers smoking, alcohol, work, and habits. Pills and supplements are not filed there. Nobody checking her drugs before surgery would think to look in that part of the chart.
Testing Pearls
- The medication list covers prescriptions plus over-the-counter vitamins, minerals, and herbs.
- Ask women directly about contraceptive pills; many do not call them medicine.
- Warfarin (Coumadin) slows clotting, so the surgeon must know about it before surgery.
- Update the medication list at every visit and keep it in the permanent chart.
- Ask about allergies to medicines, pollen, and food while you take the drug list.
References
- American Academy of Ophthalmology. Ophthalmic Medical Assisting: An Independent Study Course. Chapter 8, Comprehensive Medical Eye Examination.
