Treatment Plan Summary (Herbal Medicine)

Patient: [Name, MRN, DOB per local policy]
Plan Start Date: [Date longitudinal plan began]
Last Updated: [Current date]
Author: [Name and credentials]
Care Setting: [Care setting]
Data Sources for This Update: [patient report / medication & supplement bottles reviewed / EHR medication list reviewed / outside records & labs]

Disclaimer: This plan summarizes recommended therapies and monitoring; product quality and patient response may vary.

Active Problem List

(List only problems being addressed with herbal therapy. Prioritize by safety/acuity, then severity, then patient priority.)

• [Problem name] — Status: [controlled / improving / stable / worsening / unresolved / uncertain diagnosis]; Severity/Impact: [brief descriptor or scale with date]. (Do not mark "stable" without recent supporting data—note "no new data since [date]" if applicable.)
• [Problem name] — Status: [controlled / improving / stable / worsening / unresolved / uncertain diagnosis]; Severity/Impact: [brief descriptor or scale with date].

Key Comorbidities Influencing Herbal Safety/Selection: [Pregnancy/lactation, hepatic disease, renal disease, anticoagulation/bleeding risk, transplant/immunosuppression, active cancer therapy, HIV therapy, seizure disorder, bipolar/mania risk, other high-risk states] (Omit if none applicable.)

Therapeutic Goals

(State measurable, time-bound goals for each active problem. Include metric/scale and target timeframe.)

• [Problem name]: [Goal statement with metric and timeframe]
• [Problem name]: [Goal statement with metric and timeframe]

(If goals not yet elicited: "Goals not yet clarified—obtain at next visit.")

Current Herbal Regimen

Product/Common Name	Botanical Name (Latin binomial) & Plant Part	Preparation/Form	Dose & Frequency	Start Date	Duration/Review Date	Indication	Key Precautions
[Product name]	[Genus species, plant part]	[tea / tincture / capsule / standardized extract / topical / formula]	[Dose with units and frequency]	[Start date]	[Planned duration or review date]	[Problem reference]	[sedating / bleeding risk / CYP interaction / avoid in pregnancy / other]
[Product name]	[Genus species, plant part]	[Form]	[Dose & frequency]	[Start date]	[Duration/review date]	[Indication]	[Key precautions]

(Optional details to add when known: manufacturer/brand, standardization or extract ratio, third-party quality verification, adherence status. If a product addresses multiple problems, list once and cross-reference in Plan by Problem.)

Concurrent Therapies Affecting Safety

• [Prescription medications with material interaction potential]
• [Non-herbal supplements with overlapping pharmacology]
• [Relevant lifestyle/behavioral interventions]

(See EHR medication list for complete prescription medications. Omit this section if no concurrent therapies affect herbal safety.)

Response to Date

(For each active problem, document baseline, current status, adherence, tolerability, and interpretation.)

• [Problem name]
  • Baseline: [symptom/scale value and date]
  • Most recent: [symptom/scale value and date]
  • Objective markers: [labs/vitals with dates, if applicable]
  • Adherence: [what patient actually took]
  • Tolerability/Adverse effects: [Patient reports... / None reported]
  • Interpretation: [improving / stable / worsening / unclear due to adherence or confounders]
• [Problem name]
  • Baseline: [symptom/scale value and date]
  • Most recent: [symptom/scale value and date]
  • Objective markers: [if applicable]
  • Adherence: [summary]
  • Tolerability/Adverse effects: [summary]
  • Interpretation: [summary]

(If newly initiated: "Response not yet assessed (initiated [date]).")

Monitoring & Safety Plan

Safety Screening Status

• Allergies/intolerances (including prior botanical reactions): [complete / incomplete] — [details]
• Pregnancy/lactation: [status and date assessed, if relevant]
• Hepatic function: [known / unknown] — [last labs/date if available]
• Renal function: [known / unknown] — [last labs/date if available]
• Bleeding risk/anticoagulant use: [agent/dose or none; INR/platelets if applicable]
• Sedation/impairment risk: [risk factors and counseling provided]
• Seizure history: [yes / no / unknown]
• Mood activation/mania risk: [yes / no / unknown / not applicable]
• Immunocompromised state: [yes / no / unknown]
• Planned procedures/surgery: [date if known] — [stop/hold guidance]

(For unknown items where the regimen carries related risk: "Unknown—must assess before start/titrate; Next step: [action].")

Interaction Review

Herb-drug interaction screen performed [date] using [resource/tool].

• [Clinically actionable interaction]: [risk summary] — Plan: [adjust / avoid / monitor]

(Include only interactions warranting clinical action.)

Monitoring Schedule

(Include only if specific monitoring is indicated; omit this subsection if none required.)

What to Monitor	Frequency	Responsible Party	Action Threshold
[Symptom / scale / lab / vital]	[Frequency/timeframe]	[patient / clinician / lab]	IF [threshold] THEN [action]

Escalation & Referral Criteria

Urgent (same-day/ER)

• IF [severe allergic reaction, anaphylaxis, syncope, chest pain, severe bleeding, severe jaundice, suicidal ideation] THEN [seek emergency care immediately].

Clinical Reassessment (days to weeks)

• IF [no clinically meaningful improvement] BY [specific date] THEN [schedule reassessment/modify regimen].
• IF [worsening function or intolerable side effects] THEN [reduce dose/hold agent and contact clinic within 24–72 hours].
• IF [abnormal labs or suspected interaction] THEN [hold implicated product and contact clinician within 24–48 hours].

Specialty Referral Triggers

• IF [suspected hepatotoxicity] THEN [Hepatology referral/hepatic workup].
• IF [arrhythmia or cardiovascular symptoms] THEN [Cardiology referral].
• IF [mania or suicidality] THEN [urgent Psychiatry evaluation].
• IF [pregnancy exposure or planned conception] THEN [OB consultation].
• IF [upcoming surgery/procedure] THEN [perioperative/anesthesia consult for hold guidance].

Plan by Problem

[Problem name]

Assessment: [1–3 line summary of current status and key factors].

• Interventions: [Reference regimen items by product name; include non-herbal measures if applicable].
• Rationale: [Brief mechanism, traditional use, or evidence category].
• Problem-Specific Monitoring: [What to track and when].
• Next Decision Point: [Criteria or date for dose change, add/remove product, or escalation].

[Problem name]

Assessment: [Brief summary].

• Interventions: [Regimen table references].
• Rationale: [Brief].
• Problem-Specific Monitoring: [Brief].
• Next Decision Point: [Brief].

Informed Consent Summary

(Include when risk is meaningful—higher-risk botanicals, significant interaction potential, or uncertain evidence. Omit for low-risk, routine plans.)

• Patient agreed to: [start / continue / stop / avoid specific products].
• Key counseling points provided: [benefits, risks, interaction potential, quality variability, pregnancy/sedation/bleeding cautions as relevant].
• Attestation: Discussion included benefits, risks, alternatives, and uncertainties; patient verbalized understanding and consent.