When is a Medication Review Not a Medication Review?
When it’s just a code.
A practice recently reached out to us after this very issue was picked up during a CQC inspection.
Their medication review figures looked reassuring on paper. Reviews had been coded as completed. But when CQC followed those codes into the clinical record, the underlying documentation did not consistently demonstrate that a meaningful medication review had actually taken place.
In some cases, it appeared that the review code had effectively become a tick-box exercise.
Interestingly, this isn’t the first time we have seen this. We identified the same issue during previous CQC support work with another GP practice.
As pharmacists, we all understand the pressures of working through medication review lists, QOF requirements and clinical system searches. But recording a medication review code is not the same thing as actually undertaking one.
And that distinction matters.
What should a medication review actually look like?
NICE defines a structured medication review as a structured, critical examination of a person’s medicines, with the aim of agreeing treatment with the patient, optimising the benefits of medicines, reducing medication-related problems and reducing waste.
NHS England similarly describes Structured Medication Reviews (SMRs) as comprehensive, evidence-based reviews in which the clinician and patient work together to consider the benefits, risks and alternatives of medicines.
In practical terms, that means going considerably further than simply checking the repeat list and adding a code.
A meaningful review should consider:
Does the patient still need the medicine?
Is there a current clinical indication for each medicine? Has anything changed since it was originally prescribed?
Is it actually working?
Is the medicine achieving its intended outcome, and is it still the most appropriate treatment?
Is it safe?
Consider adverse effects, interactions, contraindications, renal or hepatic function, frailty and other individual risk factors.
Is the appropriate monitoring up to date?
Blood tests, blood pressure, therapeutic drug monitoring and other medicine-specific monitoring should be considered where relevant.
What is the patient actually taking?
The repeat medication list does not necessarily tell you what is happening at home. Consider adherence, over-the-counter medicines, complementary medicines and whether the patient understands their treatment.
What does the patient think?
An SMR should be person-centred. Concerns, preferences, treatment burden and what matters to the patient should form part of the conversation.
Could anything be stopped, reduced or simplified?
Particularly in patients with polypharmacy, a good review should actively consider whether medicines remain beneficial. Deprescribing can be every bit as important as prescribing.
And importantly: what was the outcome?
Continue, stop, reduce, increase, switch, investigate, monitor or review again – the clinical record should tell us what was decided and why.
The clinical record should tell the story
Good documentation does not mean writing an essay after every medication review.
It means leaving enough information for another clinician – or indeed an inspector – to understand what was considered, what was discussed with the patient and what decisions were made.
If ten medicines were reviewed and all ten were continued, that may be entirely appropriate.
But there should be some evidence that they were actually reviewed, rather than simply reauthorised.
This becomes particularly important with polypharmacy, high-risk medicines, frailty, renal impairment and medicines requiring regular monitoring.
Ultimately, there is a simple test:
If someone opened the patient’s record tomorrow, could they see evidence that a medication review genuinely took place?
Because a SNOMED code can tell you that a medication review was recorded.
It cannot, by itself, tell you that a medication review was done.
Yusuf
Clinical Pharmacist
PCMS