Pharmacist Desk Reference
Report Writing
Workflow Guide
Step-by-step guidance for completing Pharmacy Review and Medication Management reports.
Pharmacy Review
- Claim relatedness determinations
- Reasonable & Necessary assessment
- Formal R/N funding table
- Liability clarification
Out of scope
- Tapering plans
- Treatment recommendations
- Medication changes
Medication Management
- Active medication risk management
- Dose reduction schedules
- Prescriber engagement & coordination
- Optimisation plan with staged timeline
Out of scope
- Funding / R&N determinations
- Claim liability opinions
Step 0 — Start here
Which report has been requested?
Phase 1 — Pre-Draft
1
Read the Referral & Confirm Scope
Understand exactly what's being asked before touching anything else
✓ Do
- Identify what exactly the insurer is asking
- Is it a liability determination, excessive use, or prescribing clarity?
- Confirm accepted and declined conditions
- Identify any grey-area conditions
- Clarify any ambiguity before drafting
✗ Don't
- Start writing before understanding scope
- Assume declined = not relevant (still needs documentation)
- Confuse this with a Medication Management job
⚡ IMM Tip
- If the referral is requesting a tapering plan or optimisation — stop. That's Medication Management scope. Flag to your supervisor before proceeding.
- Accepted conditions dictate your R&N determinations — your opinions cannot exceed them.
2
Documents Reviewed Table
Table of relied-upon documents only — no commentary
✓ Include
- Documents that influenced claim relatedness
- Documents used for R&N determinations
- Documents clarifying prescribing responsibility
- Group multiple letters: "Consultation Letters | Dr X | 2022–2026"
✗ Exclude
- All pathology and radiology (unless determinative)
- Duplicate GP notes
- Hospital summaries if irrelevant
- Documents received but not relied upon
- Any descriptions or commentary in the table
⚡ Formatting Rule
- Table columns: Document | Author | Date — nothing else
- Adjust table width to span full page width
- Zero description permitted. If it's in the table, it only needs three data points.
3
Reason for Referral
One paragraph — anchors every opinion in the report
✓ Include
- Concise summary of what the insurer has asked
- Grammatically corrected version of the referral request
- Claimant-specific — not generic
- Max 4–5 lines, one paragraph
✗ Don't
- Copy the entire referral email
- Add medication history here
- Add any clinical opinion
- Be vague or generic
4
Accepted / Declined / Other Liability
Legal boundaries — your determinations must stay within these
✓ Rules
- Accepted conditions: match insurer wording exactly (grammar may be corrected)
- Declined conditions: must be listed — if depression declined, Sertraline determination must reflect this
- Other liability: conditions under investigation, concurrent claims, grey areas
- Factual only — no opinion in this section
⚡ IMM Tip
- If no formal acceptance documented: "No formal acceptance is documented. Assessment proceeds on the basis that this condition is not currently accepted."
- Do NOT reinterpret accepted condition wording
Phase 2 — Clinical Review
5
File Review
Extract only what influenced your determinations
✓ Ask before each dot point
- Does this influence claim relatedness?
- Does this affect R&N determination?
- Does this change risk assessment or prescribing responsibility?
- If none of the above → remove it
✗ Don't
- Write narrative paragraphs
- Include irrelevant comorbidities
- Add emotional commentary
- Write a full life history
⚡ Format
- Dot points only, with source reference: "Dr X (2024) documents persistent lumbar radicular pain unresponsive to physiotherapy."
- Lead with clinician name and year, then the finding
6
Medication Profile & SafeScript
Objective prescribing record — no interpretation
✓ Medication Table
- Dispensed in last 3 months
- PRN medicines dispensed within 6 months
- Specifically requested items
- Columns: Medication | Dosage Direction | Prescriber | Patient Indication
- Expand abbreviations ("when required")
- Write "Not provided" if missing
✓ SafeScript
- State if record found (Y/N + state)
- Alerts from last 3 months only — state month + exact wording
- E.g. "February 2026: High OMEDD Alert"
- Findings: brief, objective dispensing pattern observations
✗ Don't
- Guess brand names | Add commentary to the medication table | Include older dispensing unless historically relevant | Make R/N determinations in SafeScript findings
7
Medication Risks & Clinical Findings
The ONLY risk section — 3 to 6 themes maximum
✓ Good Themes
- Long-term opioid analgesic use
- Combined CNS depressant use
- Sedative polypharmacy
- Multiple prescriber fragmentation
- Concurrent THC and opioid analgesics
✓ Each Theme Must
- Define the risk clearly
- Explain clinical significance
- Explain why it matters for funding or liability
- Group by theme — not by individual drug
✗ Do NOT repeat this risk narrative anywhere else in the report
- No adverse effect laundry lists | No textbook pharmacology | No R/N determinations in this section
Phase 3 — Practitioner Contact
8
Treating Practitioner Contacts
Document every attempt — successful or not
✓ Outcome Options
- Agreed / Partially agreed / Declined / Deferred
- Must relate to: claim relatedness, R&N, prescribing responsibility, or reason for referral
- Unsuccessful attempts: document attempts, dates, and reason (no response, practice declined, etc.)
⚡ Unsuccessful Contacts
- Never remove unsuccessful attempts from the table
- If Claims Manager approves proceeding without contact — document this explicitly with the date
- State number of attempts and date range if closing out
9
Discussion Summary
Dot points only — neutral, no dialogue format
✓ Format
- Dot points only — no narrative paragraphs
- Neutral reporting tone
- E.g. "Tapentadol prescribed for lumbar radicular pain."
- E.g. "Dr X declined dose reduction at this stage."
✗ Don't
- Use dialogue format ("Dr X said...")
- Add narrative or commentary
- Repeat information already in other sections
Phase 4 — Determinations & Completion
10
Specific Questions
Answer each question directly — no cross-referencing
✓ Rules
- Rewrite each question clearly, then answer directly below it
- If outside scope: "This question falls outside the scope of a Pharmacy Review as it requires treatment planning."
- If no questions: "No specific questions were provided beyond the stated reason for referral."
✗ Don't
- Cross-reference other sections ("refer above")
- Attempt to answer treatment planning questions
11
R&N Opinion Table Core Output
All funding decisions live here — be decisive
✓ Columns
- Claim Related: Yes / No — must align strictly with accepted conditions
- R&N: Yes / No / Time-limited / Unclear (rare)
- Rationale: Reference accepted condition + benefit vs risk — concise and defensible
⚡ Time-Limited Requirements
- Must include exact duration, clinical reason, and reassessment trigger
- E.g. "Time-limited for 3 months pending updated specialist review."
- "Unclear" requires: what is missing, why it can't be determined, when clarification expected
✗ Rationale column must NOT
- Repeat risk themes | Provide tapering plans | Use emotional language | Include vague statements
12
Executive Summary Write Last
Copy-paste ready for claims managers — outcome-focused, max 12–15 lines
✓ 4-Paragraph Structure
- Para 1: Clear, decisive funding outcome — "Tapentadol SR is claim-related however not R&N."
- Para 2: Key clinically significant risk themes only (those affecting funding/safety)
- Para 3: Claim relatedness summary — which medications relate to accepted conditions and which don't
- Para 4: Other liability clarification (if applicable)
✗ Absolute Rules
- No narrative / No justification paragraphs
- No hedging / No "In my opinion"
- Max 12–15 lines total
- Write this LAST — after the R&N table is complete
Phase 1 — Pre-Draft
1
Read the Referral & Establish Goals
Identify what triggered the referral and what needs to change
✓ Determine
- What medication concerns triggered the referral?
- Is this about risk, optimisation, or prescriber conflict?
- Have previous IMM reports attempted medication change?
- What are realistic clinical goals? (e.g. gradual opioid reduction, benzo cessation, sedative rationalisation)
✓ Review Claim Context
- Accepted and declined conditions
- Other medical conditions influencing prescribing
- Prescribing patterns: escalating doses, early refills, multiple prescribers, long-term short-term medicines
⚡ IMM Tip
- This is intervention-focused — your entire report should answer "what to do next" and "who is responsible", not just assess liability.
- If only a funding determination is needed — that's Pharmacy Review scope.
2
Documents Reviewed Table
Same strict rules as Pharmacy Review — only relied-upon docs
✓ Include if it influenced
- Clinical risk assessment
- Medication recommendations
- Prescriber discussions
- Optimisation planning
✗ Exclude
- Irrelevant pathology
- Duplicate consultation notes
- Hospital summaries not impacting medication management
- Any commentary or description
⚡ Format
- Table only: Document | Author | Date — full-page width, no descriptions
3
Reason for Referral
Concise, specific, one paragraph — anchors the whole report
✓ Include
- Why the insurer referred the claimant
- The medication risks or concerns prompting referral
- Any specific questions asked by the insurer
- Grammatically corrected from the referral
- One paragraph, max 4–5 lines
✗ Don't
- Copy the entire referral email
- Provide medication analysis here
Phase 2 — Clinical Review
4
Relevant File Materials
Dot points — only what influences medication decisions
✓ Ask before each point
- Does this influence medication risk assessment?
- Does this inform prescribing decisions?
- Does this support a recommended change?
- E.g. "Pain specialist (2024) recommended opioid reduction due to lack of functional improvement."
✗ Exclude
- Full medical history
- Irrelevant diagnoses
- Emotional commentary
5
Current Medications & SafeScript
Objective record — includes prescriber and indication
✓ Medication Table Columns
- Medication | Dosage Direction | Prescriber | Patient Indication | Last Dispense Date
- Dispensed last 3 months (PRN: 6 months)
- Confirmed current by prescriber if not recently dispensed
- One line per strength/direction
✓ SafeScript
- Record: Yes / No / Not requested
- Alerts: last 3 months only — exact alert wording
- Findings: dispensing pattern observations (escalation, multiple prescribers, PRN inconsistency)
6
Medication Risks & Clinical Findings
3–6 risk themes — explain WHY intervention is required
✓ Themes (3–6 max)
- Long-Term Opioid Therapy
- Combined CNS Depressant Use
- Sedative Polypharmacy
- Multiple Prescriber Fragmentation
- Benzodiazepine Dependence Risk
- Ineffective Long-Term Treatment
✓ Each Theme Must Answer
- What is the specific risk?
- Why does it matter clinically?
- Why does it require active intervention?
7
Patient Current Status
Baseline status by condition domain — poor / partial / well controlled
✓ Status Options
- Poorly controlled: Significantly symptomatic, ongoing functional impact despite treatment
- Partially controlled: Some improvement, condition still impacts function or requires pharmacological support
- Well controlled: Effectively managed, minimal functional impact, stable treatment
⚡ Domains
- Only include conditions the patient has
- Delete unused domains; add relevant ones
- E.g. Neuropathic Pain, Nociceptive Pain, Insomnia, Depression, PTSD, Anxiety, Physical Function
Phase 3 — Practitioner Contact
8
Practitioner Contacts & Discussion Summary
Document outcomes and discussion points clearly
✓ Contact Table Columns
- Contact | Specialty | Date | Outcome
- Outcome: Agreed / Partially agreed / Declined / Deferred
- Outcome must relate to: medication reduction, substitution, prescribing responsibility, or optimisation
- Outcome must describe the practitioner's position
✓ Discussion Summary
- Dot points only, grouped by topic
- E.g. Topic: Opioid reduction → "GP agreed to begin gradual dose reduction of Tapentadol."
- E.g. Topic: Benzodiazepine use → "GP declined cessation at this stage."
✗ Responsible Party — Never use vague entries like "treating team" or "care providers"
- Always specify: Treating General Practitioner | Pain Specialist | Psychiatrist | Treating Specialist
Phase 4 — Recommendations & Plan
9
Recommended Medication & Treatment Changes
4-column table — direction only, not full schedules
✓ Table Columns
- Treatment Issue: The medication/class + reason for change
- Recommended Change: Direction of treatment (not full schedule)
- Responsible Party: Named clinician role (specific, not vague)
- Implementation Status: Pending / Pending discussion with doctor / Actioned by doctor / Declined by doctor or patient
✗ Don't
- Introduce new issues here — all issues must link to a risk finding
- Write detailed taper schedules (that's for Optimisation Plan)
- Use narrative explanations in the Implementation Status column
- Be overly directive
10
Medication Optimisation Plan
Staged reduction pathway — flexible, realistic, practitioner-aligned
✓ Include when
- Gradual dose reduction recommended
- Medication cessation requires staged taper
- Transition to alternative therapy is planned
- Common for: opioids, benzodiazepines, pregabalin/gabapentin, long-term sedatives
⚡ Table Format
- Columns: Current Medication | Reduction 1 | Reduction 2 | Reduction 3... (flexible staging, not fixed months)
- Dose changes must be gradual and clinically realistic
- Plan must align with treating practitioner discussions
- Note that the plan remains flexible to patient response
11
Further Actions
What, when, why, and who — specific and actionable only
✓ Each action must state
- What follow-up is required
- When it should occur (tied to clinical events, not default 3 months)
- Who is responsible
- Why it is clinically justified
⚡ If Practitioner Disagrees
- Do not present as agreed — document their position clearly
- Provide appropriate recommendation to insurer re: next steps (monitoring, specialist review, further insurer discussion)
✗ Don't write
- "Review later" | "Monitor as required" | Vague reassessment statements | Follow-up timing that defaults to 3 months without clinical justification
12
Executive Summary Write Last
4 paragraphs — high-level overview of issues, engagement, direction, outlook
✓ 4-Paragraph Structure
- Para 1: Key medication issues
- Para 2: Treating practitioner engagement
- Para 3: Recommended treatment direction
- Para 4: Expected outlook — doctor receptive / agreeable / argumentative / dismissive
✗ Don't
- Repeat discussions or plans in detail
- Write extensive pharmacological reasoning
- Write before completing the rest of the report
⚡ Final Check
- Medication risks clearly identified | Recommendations clinically justified | Practitioner engagement documented | Implementation status recorded | Optimisation plan realistic | Executive summary aligns with recommendations