Create one row for each item. Your columns should read: medication or product name; strength or dose if known; amount taken; route, such as by mouth or patch, if known; usual time; last time taken; prescribing professional or clinic; pharmacy; reason it was prescribed, in your own words; start date; and status. For status, use “taking now,” “taken sometimes,” “recently stopped,” or “unknown.” Do not combine two products in one row, even if you take them together.
Record prescription opioids exactly as the label shows when possible, including whether the label names a combination product. Then add every other prescription because interactions and continuity questions are not limited to opioids. Add nonprescription pain relievers, sleep products, cold medicines, vitamins, herbal products, and supplements. If you use more than one pharmacy or prescriber, list each one. Qualified professionals can decide which details are clinically relevant; your role is to provide an accurate record, not interpret it medically.
- Copy names and strengths from labels rather than memory when possible.
- List the amount and usual time separately from the printed prescription directions.
- Record the last dose or use time, including the date if known, without changing your use to make the list look simpler before the call unless a qualified professional directs you;