Herbal Formula/Prescription Note

Date/Time: [Date and time of order] (Include timezone if telehealth.)

Patient: [Patient full name] — [Patient identifier(s)]

Author/Credentials: [Clinician name, degree(s), license]

Encounter Type: [in-person / telehealth]

Linked Problem(s): [Associated diagnoses or problems]

Note Type: [New / Update / Refill / Discontinue]

Clinical Context

[Indication or symptom driving the regimen; therapeutic goals with measurable or observable outcomes; relevant patient preferences or constraints; prior therapies tried and responses if pertinent to rationale.] (Summarize in 2–4 sentences.)

Safety Screening

• Medication reconciliation: [Completed / Partially completed / Not completed] — [Date and information sources]
• High-risk concomitant medications identified: [None identified / Identified: list with specific agents and risk rationale / Not assessed]
• Allergies/intolerances: [Allergen(s) with reaction type and severity / No known drug or herb allergies / Not assessed]
• Pregnancy/lactation status: [Not applicable / Pregnant / Not pregnant / Trying to conceive / Lactating / Patient unsure / Not assessed] (Required if of reproductive potential.)
• Relevant organ function: [No known hepatic or renal impairment / Impairment details / Not assessed]
• Peri-procedural status: [No upcoming procedures / Upcoming procedure: details and date / Not assessed]
• Contraindication screening: [Completed — none identified / Completed — identified with mitigation plan / Pending confirmation]

Formula Specification

(Repeat for each prescribed product.)

[Product name / Formula name]

• Product type: [single herb / multi-herb formula / proprietary blend / standardized extract / tea / decoction / tincture / capsule / powder / topical / other]
• Manufacturer/Brand: [Manufacturer or brand]; Lot #: [Lot number / Not provided]; Expiration: [YYYY-MM / Not provided]
• Ingredients:
  • [Common name] (Latin binomial), [plant part], [preparation type] — [amount per dose in metric units]
  (List each ingredient. If proprietary blend, state: Proprietary blend; individual amounts not disclosed. Total per dose: [amount].)
• Preparation instructions: [Patient-friendly steps with exact measures, water volume/temperature, steep time, storage] (If applicable.)
• Route: [oral / topical / inhaled / other]
• Dose: [Numeric dose in metric units] (Use mg, g, mL; no trailing zeros; leading zero before decimals.)
• Frequency: [once daily / twice daily / every X hours / as needed with max frequency]
• Timing: [before meals / with food / after meals / bedtime / morning / Not specified]
• Maximum daily dose: [Max daily amount / Not applicable]
• Duration: [Duration in days/weeks/months with stop date or reassessment point]
• Quantity to dispense: [Total quantity]; Refills: [Number]
• Stop rules: [Explicit stop conditions, timeframe for effect, and next steps if no benefit or adverse effects occur]
• Special constraints: [Alcohol-free / Allergen avoidance / Vegetarian / Other] (Only if applicable.)

Monitoring & Follow-up

• Effectiveness metrics: [Specific clinical endpoints or patient-reported outcomes to track with reassessment timeframe]
• Safety monitoring: [Labs, vitals, or symptom checks with timing / None indicated]
• Interaction screening: [Completed / Not completed] — [Resources used] — [Outcome: none identified / potential interactions with management plan]
• Follow-up: [in-person / telehealth / phone / portal] — [Interval]

Patient Counseling

• Administration and preparation: [Key instructions provided]
• Expected benefit and timeline: [Realistic expectations discussed]
• Disclosure to care team: [Advised to share all supplement use with all clinicians]
• Product quality: [GMP/USP/NSF considerations discussed / Not discussed]
• Adverse effects and stop rules: [Potential adverse effects, warning signs, when to discontinue, when to seek care]
• Driving/sedation warnings: [Provided / Not applicable]
• Shared decision-making: [Patient agreement / Questions answered / Alternatives discussed] (If patient declines, document refusal and alternate plan.)

(Safety-critical elements — dose, route, frequency, duration, ingredient identity, contraindication screening, interaction screening, and pregnancy/lactation status — require explicit documentation. If unknown, use placeholder such as "Not assessed" or "Pending confirmation.")