How to do a structured medication review: the 7 steps

How to do a structured medication review

A structured medication review (SMR) is a scheduled, patient-centred appointment where you work through every medicine a person takes, decide together what to keep, change or stop, and record the outcome. To do one well you prepare the record first, run the consultation around a recognised framework such as the NHS Scotland 7-Steps model, then document, code and write an action letter to the GP. This guide sets out how to do a structured medication review step by step, on a simulated patient record, the way it runs in a real GP practice.

The SMR is part of the medicines optimisation work PCNs deliver under the Network Contract Directed Enhanced Service (DES). NHS England describes it as a shared, whole-person review of a patient's medicines, not a repeat-prescribing tidy-up or a two-minute reconciliation. The approach aligns with NICE's guidance on medicines optimisation, which puts the patient's priorities at the centre. That distinction matters, because it changes how you prepare and how long you allow.

The structured medication review process at a glance

There are three phases: find and prepare, review and agree, then record and communicate. Most of the quality lives in the first and last phases, which is exactly where a rushed clinic tends to cut corners. Get the prep right and the consultation is calmer; get the documentation right and the GP actions your recommendations without needing a second appointment.

Who is eligible for an SMR

Eligibility is a matter of clinical risk and judgement, not a fixed ranked list. The Network Contract DES asks PCNs to use appropriate tools to identify and prioritise the patients most likely to benefit. In practice that means running searches and risk stratification across these groups:

• People living in care homes.
• People with frailty, often flagged by the electronic frailty index (eFI).
• Problematic polypharmacy, especially where the number of medicines or the combination raises the risk of harm.
• Patients on medicines commonly associated with medication errors or needing intensive monitoring.
• People taking dependence-forming pain medicines such as opioids and gabapentinoids.

For 2025/26 the DES added patients taking antidepressants to the groups PCNs must consider, reflecting wider attention to safe review and, where appropriate, tapering. Use the practice's own search tools and clinical system prompts rather than working from memory, and always take account of every medicine the patient is on, not just the one that flagged them.

Before the appointment: preparing the record

Good SMRs are won before the patient sits down. Open the record and build a picture on one screen:

• Reconcile the medicines list. Separate repeats from acutes, check last issue dates, and look at ordering patterns. The repeat list rarely matches what someone actually takes, and order data is your best proxy for adherence.
• Pull the relevant monitoring: recent U&Es and eGFR, HbA1c, LFTs, lithium or DMARD bloods under shared care, latest blood pressure and weight. Check the current BNF or your local shared-care protocol for intervals, which vary locally.
• Read the last few consultations, any hospital discharge letters and the allergy and adverse-reaction record.
• Note what has changed: a fall, an admission, a new diagnosis, a renal or weight change that shifts dosing.
• Flag the obvious targets before you start, so the conversation has direction: an anticholinergic in someone who has fallen, a PPI running for years without review, a "when required" hypnotic that has quietly become daily.

Write down two or three questions you want answered. That keeps a 30-minute appointment from drifting.

The 7 steps of a structured medication review

The most widely used structure in UK primary care is the NHS Scotland Polypharmacy Guidance 7-Steps model. It gives you the seven steps as a repeatable order of questions, so you cover need, effectiveness, safety and the patient's own view every time. Use the table as your working structure and adapt the depth to the patient in front of you.

A worked example: Mr Ali, 78

Mr Ali is 78, lives at home with moderate frailty on the eFI, and takes 12 regular medicines. He had a fall three weeks ago. Working the steps:

• Aim. He tells you he wants to stay steady on his feet and stop feeling "fuzzy" in the mornings. That reframes the whole review around falls and sedation.
• Need and effectiveness. His antihypertensives, statin, metformin and gliclazide all have a clear indication and reasonable results, though you note a low HbA1c that raises hypoglycaemia risk in a frail older man.
• Unnecessary therapy. He is on long-term aspirin with no record of vascular disease, and an omeprazole started during a hospital stay two years ago that was never reviewed.
• Safety. Amitriptyline, prescribed years ago for back pain, is anticholinergic and sedating; a "when required" zopiclone is now issued every month. Both are STOPP hits in someone who has fallen.
• Efficiency and agreement. You propose stopping the aspirin, trialling a step-down of the amitriptyline, planning a zopiclone taper, and reviewing the PPI. He agrees to start with the amitriptyline and the aspirin, and you book a follow-up.

Notice you did not change everything at once. One or two changes with a clear follow-up is safer and far easier to attribute if something shifts.

Using STOPP/START and deprescribing safely

STOPP/START version 3, published in 2023 in European Geriatric Medicine by O'Mahony and colleagues, expanded the criteria to 190 statements covering potentially inappropriate prescribing (STOPP) and prescribing omissions (START) in older people. Treat it as a prompt sheet at step 5, not a set of orders: each hit is a question to weigh against this patient, not an automatic stop. Our interactive STOPP/START v3 reference and drill lets you rehearse spotting the common ones, and there is a fuller walkthrough in STOPP/START criteria explained.

When you do decide to stop or reduce, deprescribe deliberately:

• Change one thing at a time where you can, so cause and effect stay clear.
• Taper dependence-forming medicines rather than stopping abruptly. For antidepressants, the Royal College of Psychiatrists' guidance on stopping antidepressants is the reference most reviewers use; the Specialist Pharmacy Service (SPS) has practical withdrawal resources for opioids, gabapentinoids and hypnotics.
• Safety-net explicitly: tell the patient what to expect, what would count as a problem, and who to contact.
• Agree the monitoring and the review date, and write both into the plan.

You can rehearse this decision-making on a simulated record before you ever apply it in clinic.

Documenting, coding and the outcome letter

An SMR that is not recorded properly is hard to defend and easy to repeat by accident. Document the reasoning, not just the change: what you found, what you discussed, what the patient decided, and what you are monitoring. Then code it so it counts and so colleagues can find it.

• Code the review itself with the structured medication review SNOMED CT concept, plus codes for the specific outcomes and any medicines stopped or changed. If coding is where you feel least sure, clinical coding and SNOMED codes for GP pharmacists covers the practical choices.
• Write the action letter to the GP so recommendations can be actioned quickly, which matters most when you are not the prescriber. Keep it specific: the change, the reason, the monitoring and the follow-up. There is a template and worked examples in how to write a medication review action letter to a GP.

Written up in your own words, an SMR also gives you strong material for CPD. The GPhC asks pharmacists for four CPD records, one peer discussion and one reflective account each year, and from January 2026 you can choose any of the nine standards for your reflective account. A single SMR touches several of them.

Building the skill deliberately

Nobody runs a clean SMR on their first attempt; you learn the job by doing the job. If you are moving into general practice, the quickest way to get fluent is to work real-shaped cases on a simulated record, get a verdict on whether each decision was good, missed or unsafe, then reflect in your own words on what you would change next time. The competency-mapped curriculum sequences the underlying skills, and both it and the labs map to our nine-domain competency framework (the Academy's own reference, not a regulator standard).

When you are ready to test yourself, work through the medication review lab in our scored Practice Labs and make the mistakes there, not on a patient.

Frequently asked questions

What is the difference between a structured medication review and a medication review?

A structured medication review is a scheduled, shared appointment that considers all of a patient's medicines using a recognised framework, delivered under the Network Contract DES. A general medication review can be lighter, such as a repeat reauthorisation or a reconciliation after discharge. The SMR is the deeper, whole-person version.

Who is eligible for a structured medication review?

Eligibility is based on clinical risk rather than a fixed list. Priority groups under the Network Contract DES include care home residents, people living with frailty, problematic polypharmacy, patients on medicines linked to errors or needing close monitoring, and people on dependence-forming pain medicines. Antidepressants were added to the groups PCNs must consider for 2025/26.

What model should I use to structure an SMR?

The NHS Scotland Polypharmacy Guidance 7-Steps model is the most widely used in UK primary care. It moves through aim, need, effectiveness, safety, efficiency and patient agreement, which keeps the review consistent and patient-centred.

How long does a structured medication review take?

There is no nationally fixed length. Practices commonly allow around 30 minutes, and complex polypharmacy needs longer, plus preparation time beforehand and documentation afterwards. Check your local arrangements.

Do I need to be a prescriber to do an SMR?

No. You can conduct an SMR without being an independent prescriber, but any change to prescribing must be actioned by an appropriate prescriber unless you are prescribing within your own competence and local governance. This is why a clear action letter to the GP matters.