Medication Review

Medication Review


       Role of medication review in patient care

       Components of medication review

       Types of drug related problems


After completion of this session, student will be able to:

       Explain the role of medication review in patient care

       Outline the components of medication review

       List the types of drug related problems


       Medication review involves review of a patients medication regimen to ensure that therapy is safe, appropriate, efficacious and cost effective

       This can be achieved by pharmacists attending ward rounds on a day-to-day basic and applying their knowledge of therapeutics

Goal of Medication review

       Optimize drug therapy and patient health outcome by identifying and solving drug-related problems and

       Ensuring that all therapeutic objectives are being achieved

Significance of Medication Review

Daily review enables

a)      Assess whether desired therapeutic outcomes are being achieved

b)      Monitor for drug related problems

c)       Ensure rational and quality use of medicines

d)      Assess patient compliance

e)      Assess the completeness of medication charts

Components of Medication Review

       Medication order review/ Treatment chart review

       Clinical review/ Daily progress review

       Detection and management of ADRs

Medication order review (MOR)

       It is a systematic review of a patients drug therapy to ensure that the prescribed medication is appropriate for the patient

       This involves the assessment of all current and recent medication orders, including routine medication and OTC and use of other systems

Goal of MOR

       To optimize the patients drug therapy by ensuring that patients receive the right drug, dose and dosage form for the right duration

Steps in MOR

       Collection and interpretation of patient-specific information

       Assessment of therapeutic goals

       Identification of drug related problems

       Individualizing medication regimens

       Monitoring of treatment outcomes

       Medication chart endorsement


Collection and interpretation of patient-specific information

  1. Patients demographics
  2. Social history
  3. Presenting complaints
  4. Past medical history
  5. Allergy and sensitivity status
  6. Current and recent medication
  7. Lab investigations



       Case notes

       Observational charts

       Lab results &

       Discussions with medical and nursing staff

Medication history interview

       Sometimes medical staff may collect incomplete or inaccurate information about drugs

       Medication history interview (MHI) is defined as obtaining accurate information on patients’ medication use that may assist in the overall healthcare of the patient


  • The ultimate goal of medication history interview is to individualize the medication order to ensure the rational drug use. This can be achieved by:

§  Gathering the accurate and relevant information on medication use

§  Comparing the obtained information with the information collected by the other healthcare professionals  (medication reconciliation)


It enables the pharmacists to:

§  Establish the rapport with the patient

§  Explain their role in the patient management

§  Conduct preliminary medication counseling

§  Plan the ongoing patient management / pharmaceutical care

Aspects to be assessed

·         History of previous allergies and/or ADRs

·         Indication / purpose of drug use

·         Dosing regimen

·         Perceived efficacy of each drug

·         Perceived side-effects/ allergies to medicine

·         Adherence to drug regimen

·         Potential drug – drug or drug food interactions

·         Drug administration techniques

·         Use of medication aids

·         Use of prescription and /or non-prescription medications

·         Specific problems relating to medication use

·         Immunisation status (if relevant)

·         Possibility of pregnancy in women of childbearing age

·         Social drug use (alcohol, tobacco, pan masala etc)

·         Evidence of drug abuse

·         General attitudes towards illness and medication use

·         Treatment with other system of medicines (e.g., Ayurveda, Siddha and Unani)

Assessment of therapeutic goals

       Cure of the disease

       Reduction/elimination of signs and symptoms

       Arresting or slowing disease progression

       Preventing disease/symptoms

       These goals should be tailored to the patients individual circumstances and may differ from patient to patient

Identification of drug related problems

       A drug related problem is an event or circumstance involving drug treatment that interferes with patient achieving optimum outcome of medical care

       Eight categories of drug related problems were outlined

Drug related problems

  1. Untreated indication
  2. Improper drug selection
  3. Subtherapeutic dose
  4. Overdosage
  5. ADRs
  6. Failure to receive drugs
  7. Drug interactions
  8. Drug use without indication


Individualising Medication Regimens

       This is important for patients with chronic diseases who are on many drugs on a long term basis

       The main aim is to simply the regimen as much possible and to adjust the regimen for long term medication adherence

These include

       Switching to slow release formulations of same drug

       Using a different route of administration

       Changing the time at which doses are taken

       Switching to cheaper but effective and safe medication

       Combination formulation to replace two drugs

Monitoring of Treatment Outcome

       This is the key to assess whether the therapeutic goals of drug treatment have been achieved

Involves review of

  • Patients clinical status,
  • Laboratory data
  • Other markers of drug therapy response

Disease or condition

Some common outcome parameters


Occurrence of angina/B.P/Heart rate


Blood glucose levels, Body weight,HbA1c

Acute Gout

Uric acid levels,Pain,Redness

Medication Chart Endorsement

Medication Chart Endorsement

       Chart endorsement is one of the primary responsibilities of the pharmacist in ensuring that medication orders are unambiguous, legible and complete

       It is important to avoid medication errors


       Is the identity of the patient (name and medication chart) on each medication chart?

       Is the allergy status of the patient documented?

       Is the medication name clear? (AZT)

       Is the drug prescribed by the generic name?

       Is the dose clear? (units)

       Is the route, time and date of administration clear?

       Is a minimal dose interval stated? (paracetamol)

       Are additional dose administration instructions given when appropriate? (Aspirin)

       Is there any over writing?

       Has the medication chart signed by a nurse each time a dose was due?


       The pharmaceutical care provided by the pharmacist should be an integral part of the patients medical record

Daily progress review/Clinical review

       Clinical review is the review of the patients  progress for the purpose of assessing therapeutic outcome

       Should be performed on daily basis


       Assess the response to drug treatment

       Evaluate the safety of the treatment regimen

       Assess the progress of the disease and the need for any change in therapy

       Assess the need for monitoring, if any

       Assess the convenience of therapy


       It should be done daily for all the patient

       It is carried out every day by attending ward rounds

       To evaluate patients response, we need to review biochemical, hematological, microbiological and other investigations


  1. Case notes
  2. Observational charts
  3. Discussion with patient and health care professionals

       This data should be interpreted to assess whether or not progress is being made towards the targeted objectives


       MOR is a systematic review of a patients drug therapy to ensure that the prescribed medication is appropriate for the patient

       MHI is defined as obtaining accurate information on patients’ medication use that may assist in the overall healthcare of the patient

       Clinical review is the review of the patients  progress for the purpose of assessing therapeutic outcome

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