Medication reviews are recommended annually for older patients. A medication review is a discussion of a patient’s complete set of medications, but the actual content of a review is not well specified. The medical literature suggests that it is an exhaustive evaluation, but what physicians actually ask about their patients’ medication regimens has been little studied. To describe what physicians do when they review medications in the office setting. Qualitative content analysis of audio-taped encounters between 100 patients aged 65 and older and 28 primary care physicians in two health care systems in Sacramento, California. Physicians use a combination of non-mutually exclusive strategies when reviewing chronic medications that include: (1) efforts to obtain a complete list of patient medications (36% of visits), (2) discussion of a topic related to the management of each of a patient’s chronic medications (47% of visits), and (3) sequential discussion of the majority of a patient’s medications without intervening discussion (45% of visits). Of 10 medication management topics that were discussed in medication reviews, a mean of 1.5 topics (SD = 1.7, range 0–7) were mentioned for each medication, with efficacy and directions being most common. Physicians conducted a sequential discussion that included discussion of each of a patient’s medications in only 32% of visits. Comprehensive discussions about chronic medications are uncommon in routine practice. Practical conceptualization of what constitutes a physician-conducted medication review is needed.