East Asian Herbal Medicine Prescription Note (Formula Initiation/Modification)

Date: [YYYY-MM-DD]

Patient: [Full name]

DOB: [YYYY-MM-DD]

MRN: [Medical record number]

Provider: [Name, credentials]

Note Type: East Asian Herbal Medicine Prescription Note

Linked Visit Note: [Reference to parent SOAP/progress note / N/A]

Clinical Context

Prescription intent: [new initiation / modification / continuation]

Reason for change: [Brief rationale] (Only include if modification or continuation with change.)

East Asian medicine pattern diagnosis: [Pattern name(s)] (If incomplete, write "Pattern differentiation: pending" and specify missing information.)

Biomedical diagnosis: [Diagnosis / N/A] (Include if used in this clinical setting.)

Target symptoms/functional goals: [Brief description]

Prior formula and changes: [Ingredients added/removed/adjusted; form change; clinical rationale] (Only include if modification.)

Prescription Order

Formula name: [Exact local/pharmacy name]

Dosage form: [granules / raw herbs for decoction / pills / tablets / capsules]

Dose, route, frequency: [e.g., "3 g by mouth twice daily"] (Use plain language; metric units; leading zeros for values less than 1; no trailing zeros.)

Duration/quantity: [e.g., "30 days" or "180 g"]

Start date: [YYYY-MM-DD]

Manufacturer/brand: [Brand name / N/A]

Preparation instructions: [Form-specific instructions: mixing for granules, reference to clinic decoction protocol for raw herbs, or pill strength for prepared forms]

Dispense/refills: [Dispense amount] | [Number of refills authorized / 0]

Formula components: (If proprietary product with unknown ingredients, document "Ingredients not available" and plan to obtain.)

Local name	Latin binomial (part)	Dose per day	Critical notes
[Local/common name]	[Latin binomial] ([plant part])	[Dose in g or mL]	[Processing method, substitutions, pregnancy cautions]
[Additional ingredients as needed]

Safety Review

• Allergies/sensitivities: [Reviewed—no issues / Reviewed—issue present: details] (Include botanicals, foods, excipients.)
• Medication reconciliation: [Completed—current medications, supplements, and herbals reviewed / Not completed—reason and plan]
• Pregnancy/lactation status: [pregnant / lactating / not pregnant / not lactating / unknown]; Source: [patient report / test with date] (Do not infer; document source.)
• Key risk states reviewed: [Anticoagulant/antiplatelet use, planned procedures, hepatic disease, renal disease—note any issues present]
• Interaction review: [No known major interactions identified / Potential interactions: details and mitigation]

Instructions & Follow-Up

Patient counseling: [Provided / Not provided—reason and alternative]

• Preparation and administration: [Form-specific instructions]
• Expected timeline for improvement: [Timeframe]
• Stop/seek-care triggers: [Signs of allergic reaction, severe GI symptoms, bleeding, jaundice, or formula-specific cautions]
• Disclosure: Patient advised to inform all clinicians and disclose herbal use prior to procedures.
• Teach-back: [Patient demonstrated understanding / Not performed—reason]

Follow-up: [Reassessment interval or date] | Monitor: [Target symptoms, adverse effects, adherence] | Contact clinic if: [Criteria] | Seek urgent care if: [Criteria]