Herbal Medicine Consultation Note

Finished note

Example — generated by Notat from a sample visit

Reason for visit:
Follow-up for a persistent cough and reduced energy over the past 10 days.

Assessment:
Symptoms are improving. No red flags identified during today's review.

Plan:
Continue supportive care, review worsening symptoms, and follow up if symptoms do not settle as expected.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Herbal Medicine Note

Patient Identification: [Patient name, age, gender, presenting complaint or reason for visit]

History of Present Illness:
[Description of current symptoms, onset, duration, severity, associated factors, previous treatments tried, and response]

Past Medical History:
(hyphenated list)
- [Relevant medical conditions]
- [Surgical history]
- [Hospitalizations]

Medications:
(hyphenated list)
- [Current prescription medications]
- [Over-the-counter medications]
- [Herbal supplements: name, dose, frequency, duration]

Allergies:
(hyphenated list)
- [Drug allergies]
- [Food allergies]
- [Environmental allergies]

Family History:
(hyphenated list)
- [Relevant family medical conditions]

Social History:
(hyphenated list)
- [Tobacco use: type, amount, duration]
- [Alcohol use: type, amount, frequency]
- [Recreational drug use: type, amount, frequency]
- [Dietary habits]
- [Physical activity]
- [Occupation]
- [Living situation]

Physical Examination:
(hyphenated list)
- [Vital signs with units] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Relevant system findings] (Format as "System: Exam findings", one system per line)

Investigations:
(hyphenated list)
- [Laboratory results]
- [Imaging results]
- [Other relevant tests]

Herbal Medicine Assessment:
[Summary of patient’s condition, suitability for herbal therapy, and rationale for herbal intervention]

Herbal Medicine Plan:
(hyphenated list)
- [Herbal remedy: name, dose, route, frequency, duration]
- [Source and preparation instructions]
- [Potential interactions and contraindications]
- [Monitoring plan for efficacy and adverse effects]
- [Patient education and counselling]
- [Follow up plan]
- [Return precautions]