Dispensing Record (Herbal Product)

Patient Name: [Patient full name]

DOB: [Date of birth]

MRN: [Medical record number, if available]

Date/Time of Dispensing: [Date and time of dispensing]

Dispensing Location: [Clinic/site name and location]

Dispensed by: [Name, role/credentials]

Dispensing Context

[Brief summary of reason for use, whether new start or refill/continuation, and reference to associated care plan or encounter if applicable] (Use 1–3 sentences. If indication was not provided, state "Indication not provided." Do not infer clinical details not documented.)

Safety Screening

• Medication/supplement list reviewed today: [Yes / No / Partial] — [Brief comments or "Not available - reason"]
• Allergies or sensitivities: [List relevant allergies/sensitivities, or "None reported," or "Not available - reason"]
• Key risk factors assessed:
  • Pregnancy/lactation: [Assessed / Not assessed - reason] — [Status if known]
  • Hepatic/renal disease: [Assessed / Not assessed - reason] — [Status if known]
  • Anticoagulant use: [Assessed / Not assessed - reason] — [Status if known]
  • Upcoming procedures: [Assessed / Not assessed - reason] — [Status if known]
• Interaction screening performed: [Yes / No] — Issues identified: [None / Yes - description / Unable to complete - reason]

(Document what was actually reviewed or obtained. If safety-relevant information is unavailable, specify what is missing and why. Do not infer pregnancy status, comorbidities, or concurrent medications.)

Product(s) Dispensed

(Repeat the following subsection for each product dispensed.)

Product [#]

Product Identity

• Name and dosage form: [Product name; brand/product line if applicable; dosage form]
• Strength/concentration: [Concentration or strength as stated on label]
• Botanical identification: [Latin binomial, common name, plant part as labeled] (For multi-ingredient formulas, note "multi-ingredient blend" and list key botanicals or indicate if full ingredient list is attached.)
• Manufacturer/distributor: [Name as on label]

Traceability

• Lot/batch number: [Exact lot/batch code as on label or inventory record]
• Expiration/Beyond-use date: [Date as labeled]
• Quantity dispensed: [Count / grams / mL]
• Source: [clinic stock / compounded onsite / third-party / patient-supplied]
• Dispensing exceptions: [Description of missing traceability information and explanation, or "None"]

Directions for Use

• Dose and route: [Dose amount and route of administration]
• Frequency: [Frequency in plain language]
• Start date: [Planned or actual start date]
• Duration or stop/review date: [Duration or review date]
• Hold/stop parameters: [Conditions for discontinuation, if instructed]
• Preparation instructions: [Dilution, decoction, or other preparation steps, if applicable]

(Avoid "use as directed" unless detailed written directions are attached.)

Indication: [Target symptom, condition, or goal] (If not provided, state "Indication not provided.")

Counseling Provided

• Counseling offered: [Yes / No] — Accepted/declined: [Accepted / Declined] (If declined or not completed, document reason.)
• Counselor: [Name and role/credentials]
• Mode: [in-person / phone / telehealth / written materials]
• Topics covered: [1–2 sentence summary of key topics discussed, such as product use, dosing, storage, potential adverse effects, interaction cautions, self-monitoring]
• Comprehension check: [Performed / Not performed] — [Summary of patient understanding]

Monitoring and Follow-up

• Monitoring parameters: [Symptoms to track, self-monitoring details]
• Follow-up plan: [Timeframe and modality]
• Escalation instructions: [When and how to seek urgent care]

(If no specific monitoring plan applies: "No specific monitoring plan; patient advised on routine precautions and when to seek care.")

Adverse Events or Product Concerns

(Include only if patient reports a current or prior adverse event or product quality concern. Otherwise, document: "No adverse events or product complaints reported.")

• Event/concern description: [Description]
• Onset and severity: [Date/time of onset; severity]
• Actions taken: [Discontinued / dose changed / referred / other]
• Reported to manufacturer or safety pathway: [Yes / No] — [Details if reported]

Attestation

Dispenser Signature: [Name, credentials, date/time]

Patient Acknowledgment: [Signature or verbal confirmation of receipt, if obtained]

(If any information is corrected after initial entry, add an addendum specifying who, when, and what was changed.)