Herbal Medicine SOAP Note

Date/Time: [Date and time]

Visit Type: [initial / follow-up]; [in-person / telehealth]

Patient: [Patient name and identifiers]

Provider: [Provider name and credentials]

Chief Concern: "[Patient-stated concern in quotes]" / [brief clinical descriptor]

Subjective

[Interval history or History of Present Illness] (Summarize onset, duration, frequency, severity, quality, location, progression, aggravating/relieving factors, prior treatments and responses, and patient goals in a single concise paragraph. For follow-up visits, include symptom trajectory since last visit, adherence to prior plan, and any adverse effects experienced.)

Medications & Supplements:

• [Medication/supplement name (Latin binomial for botanicals)] — [dose and formulation] — [route and frequency] — [indication] — [adherence] — [verification source: patient report / bottle reviewed / pharmacy list / EMR]
• (Repeat for each item. If patient cannot recall product details, document explicitly and note plan to obtain bottles/photos.)

[Medication/supplement list reviewed and updated today]

Allergies: [Allergen] — [reaction type] — [severity: mild / moderate / severe] — [true allergy / intolerance] (List each allergen including medications, foods, and botanicals. Distinguish true allergy from intolerance when possible.)

Safety Screening: [Safety summary] (Document: pregnancy/lactation status; liver function status; kidney function status; bleeding risk and anticoagulant/antiplatelet use; and interaction screening performed. If interaction check was done, specify the database/tool used, medications/supplements screened, and result. For any domain not assessed, document "not assessed" with reason and action item to obtain. Do not document "no interactions" unless an interaction screen was actually completed.)

Objective

Vitals: [Relevant vitals] (If not obtained, state why.)

Exam: [Pertinent examination findings by system] (For telehealth, document observable elements and limitations.)

Data: [Relevant labs, imaging, outside records with dates] (Flag abnormal values relevant to botanical safety, e.g., liver enzymes, renal function, coagulation parameters.)

Assessment

(List problems in priority order. For each problem, include working diagnosis or symptom-based assessment, current status/severity, key supporting findings, and brief statement on botanical therapy appropriateness with risk/benefit framing.)

[Problem 1]: [Working diagnosis] — [status/severity] — [key supporting findings] — [botanical appropriateness statement]

(Optional) Traditional/Pattern Diagnosis: [Pattern/constitution] (Only if used by practice; do not substitute for biomedical assessment.)

[Problem 2]: [Working diagnosis] — [status/severity] — [key supporting findings] — [botanical appropriateness statement]

(Continue for additional problems as needed.)

Plan

(Organize by problem, mirroring Assessment.)

[Problem 1]

Botanical Recommendations:

• Identity: [Common name], [Latin binomial], [plant part], [preparation/form], [strength/standardization if known]
• Dosing: [Dose with units] — [route] — [frequency] — [timing] — [duration] — [refill plan]
• Indication: [Target problem] — [expected benefit and time-to-effect]
• Safety: [Patient-specific contraindications/precautions] — [interaction counseling provided] — [adverse effects to monitor] — [stop rules: "hold and contact clinic if..."]
• Monitoring: [Method to assess response] — [follow-up interval]
• Dispensing: [Brand] — [lot number] — [quantity] (Include only if dispensing from clinic.)

(Repeat botanical structure for each botanical recommended or continued.)

Other Interventions: [Lifestyle, dietary, and behavioral recommendations; conventional therapies; referrals or care coordination]

[Problem 2]

(Continue with Botanical Recommendations and Other Interventions for additional problems as applicable.)

Education & Consent: [Informed consent summary] (Document options presented including watchful waiting and conventional alternatives, anticipated benefits, risks and uncertainties, how botanicals may affect other treatments, and confirmation of patient understanding and decision.)

Follow-Up: [Timeframe] — [modality: in-person / telehealth] — [what to bring: bottles/photos, symptom diary, labs] — [return precautions for adverse reactions or red-flag symptoms]