Participate in clinical settings, reviewing patient medications under supervision
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clinical medication review step by step guide pharmacist student trainee
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https://pharmaceutical-journal.com/article/ld/how-to-conduct…
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Here is your step-by-step study guide on participating in clinical medication reviews under supervision:
Participating in Clinical Medication Reviews Under Supervision
What Is a Medication Review?
A medication review (MR) is a structured, critical examination of a patient's medicines with the goal of optimising their use and improving health outcomes. It focuses on:
- Safety (identifying harmful or inappropriate medications)
- Efficacy (ensuring medicines are working)
- Adherence (helping the patient take medicines correctly)
- Minimising polypharmacy-related risks
Types of Medication Reviews
| Type | Focus | Who Leads |
|---|---|---|
| Type 1 - Prescription review | Technical check (doses, interactions, duplications) - no patient present | Pharmacist alone |
| Type 2 - Concordance / adherence review | Medication use and patient understanding | Pharmacist + patient |
| Type 3 - Comprehensive medication review (CMR) | Full clinical review of all medicines in context of the patient's conditions | Pharmacist + prescriber + patient |
As a trainee, you will most commonly start with Type 1 under supervision, progressing to Type 2 and 3.
Step-by-Step Process
Step 1 - Prepare Before Seeing the Patient
Collect all necessary data with the patient's consent:
- Medication list: drug names, formulations, doses, regimens, routes, duration, and prescriber
- Clinical data: lab results, renal/hepatic function, cultures, imaging
- Medical/surgical history and any recent hospitalisations
- Previous adverse drug reactions (ADRs) and allergies
Tip: Perform medication reconciliation first - reconcile all sources (hospital records, GP list, patient-reported medications, OTC drugs, supplements) into one accurate list before starting the review.
Step 2 - Build Rapport with the Patient
Begin with a clear introduction and establish the purpose of the review:
"Hello, my name is [name] and I am a trainee pharmacist. I'm here with [supervisor's name] to discuss your medicines today. Can I confirm your name and date of birth?"
Key goals at this stage:
- Understand what matters to the patient - their priorities, concerns, and understanding of their own treatment
- Assess whether the patient knows why they take each medicine
- Build trust - this determines the quality of information you'll receive
Step 3 - Review Each Medicine Systematically
For every medicine on the list, check the following 4 elements:
| Element | Key Questions |
|---|---|
| Indication | Is there still a valid clinical indication? Is the medicine still needed? |
| Dose | Is the dose appropriate for the patient's weight, age, renal/hepatic function? |
| Adverse effects | Has the patient experienced any side effects? Are any new symptoms drug-related? |
| Interactions | Are there any drug-drug or drug-disease interactions? |
Additional checks:
- Is monitoring in place (e.g. INR for warfarin, renal function for metformin, thyroid function for amiodarone)?
- Are any medicines duplicated (same class, same action)?
- Has any medicine been prescribed to treat a side effect of another (prescribing cascade)?
Step 4 - Identify and Prioritise Drug-Related Problems (DRPs)
Common DRPs to flag during a supervised review:
- Untreated indication - patient has a condition with no drug prescribed
- Wrong drug - drug prescribed but not optimal for indication
- Dose too low / too high
- Adverse drug reaction - current symptom is a side effect
- Drug interaction - clinically significant interaction present
- Non-adherence - patient not taking medicine as prescribed
- Unnecessary drug - medicine with no clear indication
Rank problems by clinical priority - those posing immediate safety risks first.
Step 5 - Develop a Management Plan (with Supervisor)
As a trainee, this step is done collaboratively with your supervising pharmacist or prescriber:
- Propose your recommendations (stop, start, switch, dose adjustment, monitoring)
- Discuss the rationale with your supervisor before presenting to the patient or documenting
- Use shared decision-making language with the patient:
"Given what we have discussed about the risks and benefits of this medicine, how would you feel about working together on a process for reducing your dose?"
Ensure the plan covers:
- Changes to medications (what and why)
- Any monitoring requirements
- Referrals if needed (with safety-netting advice)
- Follow-up timing
Step 6 - Check Patient Understanding and Agreement
Before closing the consultation, confirm the patient understands and agrees with the plan. Use a teach-back approach:
"So, having discussed everything, shall we recap the plan that we have agreed so that I know we haven't missed anything?"
Reassess whether the patient's ideas, concerns, and expectations have been met. Confirm they can take their medicines as intended.
Step 7 - Document Everything
Accurate documentation is non-negotiable. Record:
- All DRPs identified
- Recommendations made
- Any changes agreed upon
- Monitoring plan
- Communication sent to prescribers/other healthcare professionals
- Patient's consent to any interventions
With the patient's consent, communicate suggested interventions to prescribers through a collaborative approach. Supporting literature may be attached to strengthen recommendations.
Step 8 - Reflect After the Review
After each review under supervision:
- Reflect on what went well and what you would do differently
- Identify any gaps in your clinical knowledge (e.g. you weren't sure about a drug-drug interaction - look it up)
- Seek feedback from your supervisor
- Note any recurring patterns across patients (e.g. common DRPs in elderly patients, polypharmacy challenges)
Key Things to Watch For as a Trainee
| Watch for | Why |
|---|---|
| High-risk drugs (warfarin, insulin, opioids, digoxin, lithium, methotrexate) | Narrow therapeutic index - errors are dangerous |
| Renal/hepatic impairment | Many drugs require dose adjustment |
| Elderly patients | High polypharmacy risk; use Beers Criteria or STOPP/START tool |
| Newly prescribed medicines | Check for new interactions or duplications |
| Transitions of care (hospital discharge) | Medication discrepancies are common at discharge |
Useful Frameworks and Tools
- STOPP/START criteria - identify potentially inappropriate medicines (STOPP) and omissions (START) in older adults
- Beers Criteria - inappropriate medications in elderly patients (American Geriatrics Society)
- NO TEARS tool - Need and indication, Open questions, Tests/monitoring, Evidence and guidelines, Adverse effects, Risk reduction, Simplification
- 7-Step medication review process (iSIMPATHY) - person-centred polypharmacy review model endorsed by Royal College of Physicians UK
Summary: Your Role as a Supervised Trainee
- Prepare and reconcile the medication list before the appointment
- Observe your supervisor's consultation technique in early placements
- Systematically review each drug (indication, dose, ADR, interaction)
- Identify and prioritise DRPs - flag them to your supervisor before acting
- Contribute to the management plan under guidance
- Document findings and communicate to the team
- Reflect and seek feedback after every review
The Pharmaceutical Journal's guide and the FIP Medication Review Toolkit are both excellent references to bookmark for further study.
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