Find out what the patient takes
A medication list records prescriptions. It may not describe what the patient actually uses. Before changing treatment, ask the patient to walk through an ordinary day: which medicines they take, how much, when, and what they skip. Include injections, inhalers, creams, nonprescription products, supplements, and medicines taken only when needed.
Medication reconciliation means comparing the available lists with actual use and resolving discrepancies. A medication review goes further: deciding whether each treatment remains useful and safe.
| Establish | Useful question |
|---|---|
| Product and dose | “Can you show me the bottle or a photograph of its label? How many do you take?” |
| Purpose | “What were you told this was for?” Verify the indication in the record. |
| Actual schedule | “What did you take yesterday? What do you do on days you work?” |
| Access and tolerance | “Have cost, side effects, or difficulty taking it changed how you use it?” |
| Recent changes | “Did another clinician start, stop, or change anything? What instructions did you receive?” |
Use bottles, pharmacy dispensing information, prior notes, and discharge instructions to resolve uncertainty. A dispensing record shows that a medicine was supplied; it does not prove ingestion. Record an unresolved dose as uncertain and identify who will verify it.
The apparent failure of a blood-pressure medicine
The chart lists two daily antihypertensives. Blood pressure remains above goal, and you are considering a third. The patient explains that one prescription costs too much, so they take it every other day.
Clarify symptoms and the urgency of the blood pressure first. Then address the access problem and agree on a feasible regimen. Document actual use and reassess its effect before labeling the prescribed regimen ineffective. Increasing the prescription without recognizing the intermittent use could cause excessive treatment if access later improves.
NICE medicines optimisation, reconciliation and medication review provides a UK clinical framework; US professional roles and administrative requirements differ. For an unaffordable prescription, see medication authorization and benefit restrictions.
Decide what treatment should achieve
Name the treatment goal precisely enough to assess benefit later. “For pain” leaves open whether success means sleeping, walking to the bus, or returning to work. A preventive treatment may aim to reduce future events even when the patient feels no immediate change.
Before prescribing, agree on the expected benefit, when to assess it, and what would justify continuing, changing, or stopping. Consider the patient's priorities and the effort required: cost, dosing frequency, monitoring visits, and effects on daily life.
What does a 20% reduction mean?
In a fictional five-year study, an event occurs in 10 of 100 untreated people and 8 of 100 treated people. The relative reduction is 20%; the absolute reduction is 2 percentage points. About 50 comparable people would need treatment for five years to prevent one event: 1 ÷ 0.02.
This number needed to treat depends on the outcome, starting risk, and time period. It does not mean every fiftieth patient is helped, or that harms disappear. A patient with a much lower starting risk may have a smaller absolute benefit even if the relative effect is similar.
Separate an outcome the patient values from a surrogate, a measurement used as a stand-in. Improving a laboratory value may support a treatment decision, but does not by itself establish improved survival or function. Read what a trial actually measured, who participated, how long they were followed, and how large the benefit and harms were.
When a symptom treatment has no agreed endpoint, it can continue through habit. Write one: “Assess whether walking tolerance improves and whether daytime sedation occurs at the planned review.”
Before you send a prescription
Check the indication, allergy history and reaction, contraindications, other medicines, relevant organ function, and pregnancy or breastfeeding when applicable. Then confirm the exact formulation, route, dose, frequency, duration, and quantity. A familiar drug name can hide a different strength, release formulation, or concentration.
Read the action behind an interaction alert: avoid the combination, adjust treatment, or arrange specific monitoring. Check whether that action fits the patient and record how you addressed it.
The omitted nonprescription medicine
A patient says the prescription list is correct, then mentions a nightly “PM” pain product. Check its ingredients and dose. It may duplicate a pain medicine already taken during the day and add a sedating ingredient.
Review the total exposure and interacting medicines before recommending another sleep treatment. Ask about driving, falls, daytime drowsiness, and alcohol when relevant. Brand names alone are insufficient because products in the same brand family can contain different ingredients.
FDA drug-interaction guidance; FDA medication and supplement interactions.
Kidney function and dosing
Reduced kidney clearance can increase exposure to some drugs or their active metabolites. Check the renal dosing instructions for the particular drug and indication. A dose reduction, a longer interval, a different medicine, or no adjustment may be appropriate depending on the product.
Estimated glomerular filtration rate (eGFR) and estimated creatinine clearance are related estimates, but labels and studies may use different methods and units. Read which estimate a dose threshold expects. Near a consequential cutoff, consider whether a more accurate estimate is needed. Estimates based on a stable creatinine are also less dependable when kidney function is changing rapidly.
NIDDK: drug dosing in adults with chronic kidney disease.
Give instructions the patient can use. When prescribing a liquid, reconcile the dose in milligrams with the concentration and volume in milliliters. When replacing a prescription, state which previous order is discontinued and notify the dispensing pharmacy as needed. Ask the patient to describe how they will take the new regimen.
Make a replacement prescription unambiguous
Fictional communication example: after reviewing an older patient's blood pressures, symptoms, and regimen, you decide to reduce amlodipine from 5 mg to 2.5 mg daily. “Decrease amlodipine” leaves the patient and pharmacy to interpret the change.
New prescription: amlodipine 2.5 mg tablets. Take one tablet by mouth once daily. Dispense 30 tablets; no refills. Replaces the amlodipine 5 mg daily prescription; discontinue that order and its automatic refills.
Patient instruction: Starting tomorrow, take one 2.5 mg tablet each morning. Stop taking the 5 mg tablets. Keep a blood-pressure and symptom log for our agreed review in two weeks; contact us sooner for recurrent dizziness or readings outside the range we discussed.
The dose, supply, and review date are decisions for this fictional patient. Send the pharmacy the discontinuation as well as the new order. Ask: “Show me which bottle you will use tomorrow and how much you will take.” With permission, update whoever fills the pill organizer.
Amlodipine prescribing information. The example teaches how to communicate a chosen change; dosing requires the patient's assessment and current product guidance.
Plan monitoring before starting
Monitoring has two purposes: detecting benefit and detecting harm. Establish the relevant baseline, the first review interval, the measurements needed, and who will act on them. Repeat this assessment after a dose increase, an interacting medicine, or a change in health.
Starting an ACE inhibitor in chronic kidney disease
An angiotensin-converting enzyme (ACE) inhibitor is being started for an appropriate indication. Record baseline blood pressure, creatinine, and potassium, and review other contributors to low blood pressure, kidney injury, or high potassium.
KDIGO advises checking blood pressure, creatinine, and potassium within two to four weeks after starting or increasing a renin–angiotensin-system inhibitor in chronic kidney disease, with timing adjusted to kidney function and potassium. Higher-risk circumstances or new symptoms can require earlier review.
A small creatinine rise does not automatically mean the treatment must stop. KDIGO uses a rise greater than 30% within four weeks as a threshold that warrants reassessment of continuation. Investigate volume depletion, interacting drugs, and other causes; symptomatic hypotension or uncontrolled hyperkalemia may require action regardless of that percentage.
KDIGO 2024 CKD guideline, practice points 3.6.2–3.6.5. For handling an abnormal result, see potassium and clinical urgency.
Turn “check labs” into an order and a review
For a stable patient in the preceding example whose assessed risk permits it, the plan might read: “Repeat creatinine and potassium in two weeks. Review home blood pressures at the same time. Results go to the prescribing clinician, with coverage during absence.” The patient also needs instructions for symptoms that should prompt earlier contact.
Different treatments need different schedules. Use the current product and disease guidance rather than copying this interval to every prescription. A refill is an opportunity to check whether promised monitoring happened, whether the medicine is helping, and whether new risks have appeared. If monitoring is overdue, weigh the risks of continued treatment against the risks of an interruption and arrange a prompt review.
The refill is due today; monitoring looks overdue
A patient requests lisinopril and has one tablet left. The chart shows no recent creatinine or potassium. Confirm the indication, dose actually taken, recent changes, symptoms, and outside testing before deciding whether to renew.
In this case, the patient feels well and brings a recent outside laboratory report. You verify stable kidney function and potassium appropriate for continued treatment, unchanged dosing, and acceptable home pressures. Reconcile the report, renew the established regimen, and record the next monitoring plan. The missing information was in the record you could not yet see.
Change one fact: the patient instead reports vomiting, poor intake, and much less urine. This needs urgent clinical assessment for possible kidney injury and volume depletion. Review whether to temporarily withhold lisinopril, choose the care setting from the patient's condition, and assign responsibility for the restart decision.
If testing is truly overdue and the patient is otherwise stable, arrange it and make an individual supply decision from the indication, prior results, current risks, and risk of interruption. Record why the chosen supply is reasonable while testing is arranged, the testing and review dates, and who acts if the patient cannot complete them. A blanket refill denial and an automatic long renewal both skip that assessment.
NICE acute kidney injury guidance, recommendation 1.2.14 supports considering temporary ACE inhibitor or ARB interruption during vomiting, diarrhea, or sepsis until the condition improves and stabilizes. This is UK clinical guidance; the refill example does not prescribe a universal monitoring interval or bridge supply.
Investigate adverse effects
A new symptom may be an adverse drug effect, the underlying illness, or a new problem. Build a timeline of symptoms, drug starts, dose changes, and other exposures. Assess serious features first. Timing can support a drug explanation but cannot establish it alone.
Ankle swelling after an amlodipine increase
A patient develops bilateral ankle swelling after their amlodipine dose increases. Amlodipine, a calcium-channel blocker used for hypertension and angina, can cause dose-related peripheral edema. Review the timing, examination, and other possible causes, including cardiac, renal, venous, or hepatic disease.
If assessment supports amlodipine-related edema, reconsider its dose or the regimen before adding a diuretic simply to treat the swelling. This edema is not primarily caused by excess total-body fluid; diuretics often provide little benefit for that mechanism. Breathlessness, acute unilateral swelling, or other concerning findings require their own evaluation.
Amlodipine prescribing information; NHS Specialist Pharmacy Service: calcium-channel-blocker edema.
A prescribing cascade occurs when an adverse effect is treated as a new disease and another medicine is added. Look for this when a symptom appears after a treatment change. Improvement after a supervised reduction or withdrawal can support causation; it is not always safe or necessary to re-expose the patient to prove the point.
Describe the reaction accurately in the record. An expected intolerance and an immune-mediated allergy have different implications. Include the drug, reaction, timing, severity, and subsequent exposure when known. Leave a credible serious reaction visible while an uncertain history is being clarified.
Reduce or stop treatment
Deprescribing is a planned reduction or withdrawal when a medicine's burdens or risks exceed its expected benefit, or when the indication has ended. The aim is appropriate treatment, not the smallest possible medication count.
For each candidate, ask why it was started, whether that reason remains, whether it helped, and what could happen if it is reduced. Agree on the change with the patient and relevant prescribers. When feasible, change one medicine at a time so that a response can be interpreted; an urgent safety problem may require several changes together.
| Write down | Why it matters |
|---|---|
| Reason for the change | The indication ended, benefit was absent, harms emerged, or the patient's goals changed. |
| Reduction or stopping instructions | The plan must reflect withdrawal risk and the drug's current guidance. |
| Expected effects and warning symptoms | Distinguish a possible withdrawal response, return of the treated condition, and a new illness. |
| Review date and responsible clinician | Specify when to assess progress and how to obtain help before that date. |
| Conditions for changing the plan | State what would prompt a slower reduction, reassessment, or a different treatment. |
A long-standing nightly benzodiazepine
An older patient reports falls and daytime drowsiness while taking a benzodiazepine every night for years. Review the indication, dose, alcohol and other sedatives, prior withdrawal, and the patient's concerns about stopping.
Physical dependence can develop during prescribed use and is not synonymous with addiction. Abrupt discontinuation after regular use can cause serious withdrawal, including seizures. Discuss whether the balance favors tapering, arrange an individualized supervised plan, and treat the underlying sleep or anxiety problem. A history of severe withdrawal or other major risks may require specialist input or a higher level of care.
The patient says, “It is the only thing that lets me sleep. I cannot go through another sleepless month.” A useful response is: “Sleep matters. I am concerned that this medicine may also be contributing to your falls. We can work on sleep while making a gradual change, and adjust the pace if you have trouble.”
For a stable patient without a need for immediate transfer, agree on the first step: verify the nightly dose and withdrawal history, arrange treatment for the underlying sleep problem, and write the initial reduction and follow-up plan together. Ask the patient to repeat the instructions and identify whom to call for withdrawal symptoms. Review the response before advancing the taper.
2025 Joint Clinical Practice Guideline on Benzodiazepine Tapering; FDA benzodiazepine safety communication.
Resolve changes after discharge
After a hospital stay, compare the previous regimen, discharge instructions, what was dispensed, and what the patient is taking now. For each change, find the reason and whether it was intended to be temporary. A medicine held during acute illness can be lost indefinitely if no one makes a restart decision.
Two lists and a pill organizer
The discharge list replaces one blood-pressure medicine, but the patient has continued filling an organizer from the old bottles. They now report dizziness on standing.
Assess current symptoms, blood pressure, falls, and whether urgent evaluation is needed. Verify the exact products and doses, clarify the hospital plan, and determine which regimen is appropriate now. A duplicate-looking list can reflect an error, an intended combination, or an outdated entry; establish which before acting.
Give the patient one updated set of instructions. Address old bottles, automatic refills, pharmacy records, and the organizer so the discrepancy does not recur. Assign a clinician to review symptoms and blood pressure after the correction.
Record what you confirmed and what remains unresolved. If another prescriber must make a decision, request and confirm that handoff. For the payment requirements surrounding this work, see transitional care management.
Cases to work through
A prescription appears ineffective. The patient says they take it “most days.” What information changes your next decision?
Establish the actual schedule, dose, technique where relevant, supply, affordability, adverse effects, and duration of consistent use. Assess whether the clinical condition requires immediate action. A reasonable prescribed regimen has not had a fair trial if it was not taken as intended; the solution may be a more feasible regimen rather than another drug.
A fictional treatment lowers five-year event risk from 4% to 3%. How would you explain its benefit?
The absolute reduction is 1 percentage point: about one fewer event per 100 comparable people treated for five years. The relative reduction is 25%, and the number needed to treat is about 100 over that period. Discuss harms, burden, and whether the study population resembles the patient.
Creatinine rises from 1.0 to 1.2 after starting an ACE inhibitor. Does that number settle whether to continue?
No. It is a 20% increase, but continuation also depends on the indication, timing, potassium, symptoms, blood pressure, volume status, other drugs, and overall course. Neither “any rise means stop” nor “less than 30% means safe” is sufficient.
Dizziness improves after correcting a duplicated prescription, but exertional breathlessness remains. Is the medication explanation complete?
No. The improvement supports a contribution to dizziness, but persistent breathlessness requires its own assessment. Reconsider the remaining findings and urgency rather than forcing both symptoms into one explanation. See revisiting a working diagnosis.
The patient agrees to stop a long-term benzodiazepine and asks whether to throw it away tonight.
Clarify that agreement to deprescribe is not an instruction to stop abruptly. Verify actual use and withdrawal risk, provide a supervised taper when appropriate, and arrange support and follow-up. Severe withdrawal risk or instability may require a different care setting.