Pre-Procedure Supplement Hold Plan (Herbal Medicine)

Pre-Procedure Supplement Hold Plan

Date: [date]

Author: [name, credentials]

Procedure: [procedure type and site]

Scheduled Date/Time: [calendar date and time / Not yet scheduled]

Anesthesia: [local / sedation / MAC / general / unknown]

Procedural Team: [surgeon or dentist name and facility]

Bleeding Risk Category: [minimal / low / moderate / high / unknown]

Supplement list obtained via [patient verbal report / bottle photos / EHR review]. List is [verified / unverified]. Patient instructed to bring all supplement containers to pre-op and report any changes.

Supplement Inventory

(Repeat the following line for each supplement. If patient denies all supplement use, enter: "Denies vitamins, herbals, medicinal teas, or dietary supplements.")

Product: [product name; include botanical name if known] — Formulation: [capsule / tablet / liquid / tea / tincture / powder / other] — Dose & Frequency: [dose and schedule / unknown] — Indication: [patient-stated reason / unknown] — Last Dose: [date and time / unknown] — Notes: [single-ingredient / multi-ingredient blend—patient to provide bottle / traditional medicine formula—potentially unknown ingredients]

Hold Plan

(Provide one action line for each supplement listed above. Use calendar dates for stop instructions. If procedure not yet scheduled, use "Stop now pending scheduling" or "Finalize dates once procedure scheduled." Apply conservative default: discontinue non-essential supplements approximately 14 days before procedure when product risk is uncertain or ingredients are unknown.)

[Product name]: Disposition: [hold / continue / taper / discuss with procedural team] — Stop Date: [MM/DD/YYYY / Stop now pending scheduling / Finalize once scheduled] — Rationale: [bleeding risk / anesthesia interaction / hemodynamic / glucose / metabolism / unknown ingredients] — Resume: [Resume after surgical team clearance, typically after hemostasis confirmed]

(If patient declines a recommended hold: "Patient declines hold for [product]; risks discussed; procedural team notified.")

(For sedative-type supplements such as valerian or kava, specify: [taper prior to procedure / continue with anesthesia team awareness] with brief reasoning.)

Coordination and Counseling

• Communication with Procedural Team: [name and role contacted], via [phone / EHR message / fax], [date]. [Summary of information sent]. Response: [accepted / modified / clarification requested / pending].
• Patient Counseling: Patient advised that supplements are biologically active; instructed to disclose all supplement use to perioperative clinicians; patient [acknowledged and agreed to hold plan / declined—see above].
• Unknowns and Follow-Up Tasks: [procedure date unknown / ingredients unknown for specific product / dose unknown]. Task: [obtain bottle photos / verify formulation / confirm procedure date / reconfirm plan with procedural team]. Responsible: [name] by [date].
• Follow-Up Triggers: [procedure date changes / new supplements started / procedural team requests modifications].

(This document is a focused supplement reconciliation and hold plan; it is not a full pre-anesthesia evaluation.)