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.
“Structure a medication review for a patient on eleven medicines”“Help me write up an MTM for the prescriber”“Run a polypharmacy assessment”“How do I document a deprescribing recommendation?”“Prepare a medication use review for this patient”
What to give it
▸The medication list — prescribed, OTC, herbal and supplements, with doses and start dates
▸What the patient actually takes — including doses skipped, halved, or stopped, and why
▸The clinical context — active conditions, relevant lab values, renal and hepatic function, allergies, recent hospitalisations
▸The patient's goals and constraints — cost, swallowing difficulty, dosing burden, side effects they will not tolerate
▸Who prescribes what — multiple prescribers are where duplication and gaps hide
✅ The bar it holds itself to
Every skill in this library self-verifies — these are this skill's own quality checks, straight from its definition.
✓The list was reconciled against what the patient reports taking, not just the record
✓Discontinued and self-adjusted medicines were actively asked about
✓Every problem is classified into a named type
✓Prioritisation is by potential harm, not by how easy the fix is
✓Each recommendation states finding, rationale and one specific proposed action
✓The patient's own goals are recorded and conflicts named
✓Nothing asserts a clinical determination reserved to the prescriber
⚠️ What it refuses to do
**Reviewing the record instead of the patient.** The gap between the two is the whole finding.
**Listing without classifying.** An unclassified list is a summary, not a review.
**Leading with the easy wins.** A prescriber who reads three trivial items first stops reading.
**Recommendations without rationale.** 'Stop amlodipine' with no reason will be ignored, correctly.
**Ignoring what the patient wants.** A regimen the patient will not take is not a better regimen.