Consultation Note (Herbal Medicine, Requested Opinion)

Header Block

Date/Time: [Date and time of consult]

Author: [Name, credentials, service/department]

Encounter Modality: [in-person / video / phone / eConsult-chart review]

Information Sources: [Sources used: patient interview, caregiver, EHR review, product label/bottle, pharmacist, external records]

Requesting Clinician/Service: [Name, role, service]

Reason for Consultation: [Specific question being asked]

Scope: [one-time opinion / recommendations only / co-management requested]

[Statement regarding chart-only eConsult and data limitations] (Include only if no direct patient contact occurred.)

Executive Summary

Consult Question: [Restate specific question verbatim or near-verbatim]

Answer:

• [Direct conclusion: avoid / reasonable with precautions / insufficient data to assess safely]

Key Risks:

• [Interaction risk or class effect]
• [Patient-specific vulnerability]
• [Product-specific concern]
• [Peri-procedural or condition-specific risk] (Include only if applicable.)

Key Recommendations:

• [Start/stop/avoid/continue with parameters]
• [Monitoring with timing and thresholds]
• [Safer alternative if applicable]
• [Key counseling points]
• [Follow-up plan and responsible party]

Communication: [How and when recommendations were communicated to requesting clinician; whether urgent items were highlighted]

Clinical Background

Presenting Context: [Patient goal for supplement use; planned vs current use; start date and duration; perceived benefits; adverse effects experienced; prior supplement trials and reactions; red flags if present] (2–8 sentences in paragraph form. Include direct quotes only when they clarify intent or risk behavior.)

Current Medications and Substances:

• Prescription medications: [Name, dose, frequency, indication when relevant]
• OTC medications: [Name, dose, frequency]
• Substances: [Alcohol, cannabis, nicotine, others if interaction-relevant]
• Allergies and intolerances: [Drug/supplement allergies and prior reactions]

Medication List Reliability: [high / moderate / low / unknown] — [Basis for reliability assessment] (If patient recall only or no bottle/label verification, state explicitly.)

Relevant Medical History: [Conditions that modify supplement safety or monitoring needs] (Include only pertinent items such as: pregnancy/lactation, liver or kidney disease, bleeding disorder or anticoagulant use, seizure disorder, bipolar/psychosis history, transplant/immunosuppression, active cancer therapy, arrhythmia or QT prolongation, diabetes, upcoming surgery with timing.)

Herbal/Supplement Exposure Details

(Document each product separately. Do not infer ingredients if product identity is incomplete—state "insufficient product detail to assess safety" and specify next steps.)

[Product name as on label / common name]

• Botanical name: [Genus species] (If known.)
• Formulation: [capsule / tablet / tea / tincture / extract; standardized extract vs raw powder]
• Manufacturer/brand: [Brand] — Third-party verification: [USP / NSF / ConsumerLab / none / unknown]
• Dose and frequency: [Amount with units and frequency; specify mg of extract vs mg of herb]
• Start date and duration: [Dates and adherence]
• Patient-stated indication/goal: [Indication]
• Observed effects: [Perceived benefits and adverse effects]
• Product verification: [verified by label photo/bottle / reported from memory]

(Repeat for each additional product.)

Concomitant stacking: [Overlapping products or ingredients across blends and single-ingredient supplements] (If none identified, omit this line.)

Data gaps: [Missing product information and steps requested to obtain: bring bottle, upload label photo, confirm ingredient list] (If no gaps, omit this line.)

Objective Data

Pertinent Vitals/Exam: [Findings relevant to safety assessment] (If not performed, state "No exam performed—eConsult" or "No pertinent findings.")

Pertinent Labs: [Relevant labs with dates: INR, CBC/platelets, LFTs, creatinine/eGFR, glucose/A1c, others as applicable] (If not available, state "No recent labs available" with next steps.)

Procedural Timeline: [Surgery/procedure date and anesthesia plan] (Include only if peri-procedural planning is relevant.)

Assessment

Summary: [1–2 sentence problem representation focusing on supplement safety context and primary concerns]

Risk Tier: [High risk—avoid / Moderate risk—use with precautions / Lower risk—reasonable]

Key Risk Factors and Interactions:

• [Patient-specific risk factors]
• [Drug–herb interactions with mechanism and expected clinical consequence]
• [Herb–herb or product–product interactions]

(Distinguish documented interactions from theoretical/mechanistic concerns.)

Evidence Certainty: [limited human data / mechanistic concern only / case reports / observational data / well-documented interaction]

Recommendations

Direct Answer: [Explicit answer to consult question; safer alternatives if appropriate; if unable to assess safely, state why and what information is needed]

Supplement Guidance:

[Product name]

• Recommendation: [avoid / discontinue / continue / reasonable to trial with precautions]
• Dose guidance: [Specific dose and schedule] (Only if product identity is reliable.)
• Duration: [time-limited trial / ongoing]
• Do-not-combine warnings: [Specific agents or classes] (If applicable.)
• Peri-procedural plan: [Stop/hold timing and resume plan] (If applicable.)

(Repeat for each additional product.)

Monitoring:

• Parameters: [Symptoms, vitals, and/or labs to monitor]
• Timing: [Baseline, interval, PRN triggers]
• Stop criteria: [Red flags requiring discontinuation: bleeding, jaundice, severe sedation/falls, palpitations, rash, mood changes]

Patient Counseling: [Topics addressed: disclosure of all supplements to clinicians, "natural" does not equal safe, avoiding proprietary blends when risk is a concern, product quality and third-party verification, pregnancy/procedure precautions as applicable]

Coordination

Communication: [Method, time, recipient, urgency level, confirmation of receipt for urgent issues]

Responsibility: [Which clinician will execute each action: e.g., requesting clinician to order labs, consultant to provide alternatives, pharmacy to assist with monitoring]

Follow-up

[Consultant will follow / PRN re-consult only / signing off] — [Recommended follow-up timeframe and triggers for re-consultation] (If eConsult, note whether formal visit is recommended.)

Critical unknowns requiring follow-up: [Any unknown safety-critical information with responsible party and next step] (If all critical information is known, omit this line.)