Why a medication list helps

Medications reveal a great deal about a person's health history. They also raise legitimate care questions: Can the person manage their own medications safely? Is there a risk of missed doses or overdose? Are medications being stored correctly?

For CLSC assessments, a medication list serves two purposes:

1. It gives the assessor clinical context about the person's health
2. It directly supports a case for medication management assistance if the person is struggling

What to include

A useful medication list includes:

• Medication name (brand and generic, if known)
• Dosage (e.g., 10 mg)
• Frequency (e.g., twice daily with food)
• What it is for (e.g., blood pressure, thyroid, pain)
• Who currently manages it (the person themselves, a family member, a nurse)

Prescribed medications, over-the-counter medications, vitamins, and supplements should all be included. Interactions between them are clinically relevant.

How to get an accurate list

The most reliable source is the pharmacy. Ask for a printed medication profile — most pharmacies will provide one quickly, and some will update it whenever a prescription changes.

Alternatively, the family doctor can provide a current list as part of any appointment or through a brief administrative request.

If the person keeps their medications at home, photograph the labels of each bottle as a reference.

Document who manages medications and how

If the person is struggling to manage medications independently, describe this in writing:

• How are medications currently organized? (Pill dispenser? Left in bottles?)
• Who prepares the doses, and how often?
• Have there been any missed doses or double doses recently? Approximately how often?
• Is there any concern about the person taking medications at the wrong time or in the wrong amount?

This written description, paired with the medication list, gives the assessor what they need to evaluate whether medication management support is appropriate.

What should I gather next?

See the full Medical Documentation Checklist for other items to prepare before an assessment.