13.1 Clinical Review Process

12.1 Clinical Review Process

Quick Answer: Clinical review under Standard 3.3 is a structured, repeated process: confirm goals of therapy, compare the current regimen with those goals and the patient’s clinical status, identify drug-related problems (DRPs), prioritise by harm and urgency, agree a collaborative plan, and set follow-up. In Australia this may be informal (every dispense and counselling encounter) or formal (for example Home Medicines Review or residential medication management review pathways at awareness level for interns).

Passing the Intern Written Examination requires more than listing medicines. You must show you can monitor and evaluate whether therapy is still appropriate—efficacy, safety, adherence, and fit with the patient’s goals—and know what to do when it is not.

Why structured review matters

Medicines change over time: indications resolve, renal function declines, new diagnoses appear, adherence drifts, and interactions accumulate. A “once correct” regimen can become unnecessary, under-dosed, over-dosed, poorly tolerated, or unsafe. Structured review reduces the risk that you only notice problems when a crisis presents at the counter.

Clinical review is not the same as:

• Dispensing completeness checks (legal particulars, quantity, schedule)—necessary, but not full review
• Counselling at supply alone—education without reassessing goals and outcomes is incomplete
• Computer interaction alerts alone—software flags possibilities; the pharmacist judges clinical relevance

It is the professional process of asking: For this person, with these goals, is this medicine list still the right plan—and if not, what should change?

Steps of a structured medication review

Use a repeatable sequence so nothing critical is skipped under exam time pressure.

1. Establish context and goals of therapy

Clarify why each medicine is used and what success looks like. Goals may be curative (finish antibiotics for confirmed infection), disease-modifying (HFrEF pillars), symptom control (analgesia, reflux), prevention (statin, antiplatelet, vaccination), or substitution (opioid agonist therapy). Goals should be patient-centred: blood pressure targets, symptom relief, fall reduction, fertility plans, cultural priorities, and what the person values most.

Without goals you cannot judge “dose too low” or “unnecessary drug.” A proton pump inhibitor continued years after a short gastro-protection indication may no longer match any active goal—unless a new indication has appeared.

2. Collect a best-possible medication history

Reconcile prescribed, over-the-counter, complementary, and “as needed” medicines, including inhalers, patches, injectables, and samples. Note doses, formulations, timing, recent changes, and who is managing administration (patient, carer, dose administration aid). Cross-check allergies, adverse reaction history, adherence patterns, and recent hospital discharge lists. Discrepancies between hospital discharge and community supply are classic DRP sources.

3. Assess clinical status and monitoring data

Link the regimen to symptoms, signs, and available results: blood pressure, heart rate, weight, glucose readings, eGFR, electrolytes, INR, HbA1c, LFTs, drug levels, and red-flag symptoms (chest pain, severe dyspnoea, suicidal ideation, severe rash, black stools). Trends matter more than isolated numbers when available (see Section 13.2).

4. Identify drug-related problems systematically

Work through a standard DRP framework so categories are not missed:

Also consider missing therapy (indication present, no medicine or non-drug care) as a related gap—for example no statin after established atherosclerotic disease when not contraindicated, or no rescue inhaler with preventer-only asthma regimens when indicated by guidelines and history.

5. Prioritise problems

You will rarely fix everything in one encounter. Prioritise by:

1. Immediate safety risk (bleeding on over-anticoagulation, hyperkalaemia with ACEI + spironolactone + renal impairment, anaphylaxis risk, serotonin toxicity cluster)
2. High potential harm if delayed (uncontrolled severe hypertension with end-organ symptoms, untreated severe infection signs, suicidal risk on antidepressants)
3. Efficacy gaps affecting major outcomes (non-adherence to secondary prevention after ACS)
4. Quality-of-life and preference issues (side effects driving non-adherence, regimen complexity)
5. Lower-risk optimisation (formulation switches for convenience when stable)

Document urgency and what can safely wait for the next GP or specialist review.

6. Agree a collaborative plan

Recommendations may include dose change, switch, stop (with taper if needed), add monitoring, refer, or reinforce non-drug care. Involve the patient (goals, capacity, preferences) and the prescriber when prescription medicines change. Interns and pharmacists practise within scope: some actions are counselling and OTC optimisation; others require prescriber agreement. Communicate using situation, assessment, recommendation structure and be ready to justify with AMH/APF-aligned reasoning (restricted open-book on exam day).

7. Implement, document, and follow up

Record DRPs identified, advice given, prescriber contacts, and monitoring due dates. Set a review interval appropriate to risk (days for INR after interacting antibiotic; weeks for antidepressant response; months for stable lipids). Closing the loop is part of Standard 3.3—not optional paperwork.

Goals of therapy in practice

Make goals specific and measurable where possible:

• Hypertension: achieve individualised BP target while minimising falls, electrolyte disturbance, and renal deterioration
• Type 2 diabetes: balance glycaemic targets with hypoglycaemia risk, cardiorenal benefit of modern agents, and patient capacity
• Pain: functional goals (sleep, mobility) rather than “zero pain at any opioid cost”
• Anticoagulation: prevent stroke/VTE while keeping bleeding risk acceptable and INR/DOAC use appropriate

When goals conflict (aggressive HbA1c vs hypoglycaemia in frailty), explicit prioritisation with the patient and team is the professional response—not silent default to a single number.

Home Medicines Review and residential review (awareness level)

Interns are not expected to run full funded review programmes from memory of every item number, but should understand the clinical model:

• Home Medicines Review (HMR) concepts: collaborative, usually GP-referred process where an accredited pharmacist reviews medicines in the home context, identifies DRPs, and reports recommendations to the referrer for shared decision-making.
• Residential medication management review concepts: structured review for people in residential aged care, where polypharmacy, transitions of care, swallowing/administration issues, and high-risk medicines are common.

Both models emphasise collaboration, documentation, and follow-up, not a one-way letter. Community and hospital pharmacists also perform continuous micro-reviews at every supply and ward round; formal programmes extend depth when complexity or transitions warrant it.

Putting it together for the exam

Expect scenarios that ask you to spot the highest-priority DRP, choose the next best action (clarify history, contact prescriber, counsel, urgent referral), or select which problem is unnecessary drug vs dose too low vs adherence. Anchor every answer to goals → assessment → prioritised plan → monitoring. Structured review is how Standard 3.3 turns a medicine list into safe, person-centred care.