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medication-therapy-review

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Structure a pharmacist's medication therapy review so it finds the problems worth escalating and documents them in a form a prescriber will act on. Use when asked to conduct a medication review, run an MTM or MUR, deprescribing review, or polypharmacy assessment, or to prepare a review for a patient on many medicines. Produces the medication list reconciled, the drug-therapy-problem list classified and prioritised, the patient-goal alignment, the prescriber recommendations with rationale, and the follow-up plan. A documentation and reasoning framework for a licensed pharmacist; it makes no clinical determination and recommends no specific drug or dose.

skills/medication-therapy-review/SKILL.md

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Nov 11, 2026
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MIT

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# Medication Therapy Review

A medication review that lists twelve drugs and concludes 'continue as prescribed' helped nobody. The value is in the problems found — the duplicate therapy, the drug with no active indication, the one the patient stopped taking three months ago and never mentioned — and in writing them up so a busy prescriber can act in under a minute. This structures the hunt and the write-up.

## What This Skill Produces

- **A reconciled medication list** — prescribed, over-the-counter, herbal, and what the patient is actually taking, which is rarely the same list
- **A classified drug-therapy-problem list** — indication without therapy, therapy without indication, wrong drug, dose too high or low, adverse reaction, adherence
- **Prioritisation** — by potential for harm, not by ease of fixing
- **Prescriber-facing recommendations** — each with the finding, the rationale, and a specific proposed action
- **Patient-goal alignment** — what the patient actually wants from their medicines, which frequently differs from the guideline
- **The follow-up plan** — what to monitor, who does it, and when

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