PRESCRIPTION REFILL NOTE

Patient: [Name, date of birth]
Date of request: [Date and time received]
Request from: [Patient, caregiver, pharmacy renewal request, or portal message]
Handled by: [Name, role]
Prescriber of record: [Name]

THE REQUEST
Medicine: [Name, strength, dose, how often, and what it's for]
Quantity asked for: [Tablets or days' supply, and refills]
Last filled: [Date, quantity, and days' supply, from the pharmacy record]
Supply left: [Tablets or days left, by the patient's count or the fill dates]
Reason for the request: [Routine renewal, running out early, lost or stolen, a dose change, or travel]

ADHERENCE AND RESPONSE
How it's taken: [As prescribed, or how the patient actually takes it]
Fill history: [On-time, late, or early fills over the past year]
Is it working: [Symptoms, home readings, or goals, as the patient reports them]
Side effects: [New side effects, or none reported]

MONITORING
Last visit: [Date, and with whom]
Next visit: [Date booked, or when it is due]
Labs: [Each test the medicine needs, the last result and its date, and whether it is due]
Readings and drug levels: [Blood pressure, heart rate, weight, blood sugar, INR, or drug levels, with the last value and date]

SAFETY CHECKS
New medicines and interactions: [Prescriptions, over-the-counter products, or supplements since the last review; interactions found, or none]
Kidney and liver function: [Last eGFR and liver tests, and whether the dose still fits]
Allergies: [Confirmed, with any change]
Pregnancy: [Pregnant, planning, or breastfeeding, where it matters, or not applicable]
Controlled substances: [Agreement on file; prescription monitoring program checked, with the date and what it showed; last urine drug test; or not applicable]
Early refill pattern: [Earlier early requests, lost or stolen reports, more than one prescriber, or none]

DECISION
Protocol: [The delegated refill protocol used and each criterion met, or routed to the prescriber and why]
Decision: [Renewed, renewed a short supply until a visit, declined with a visit booked, or changed]
Prescription sent: [Medicine, dose, quantity, refills, and pharmacy, or none]
Orders: [Labs, readings, or a visit booked with the renewal]
Reason: [Why this decision, in a sentence or two]

PATIENT CONTACT
Told: [What the patient was told, how, when, and by whom]
Response: [What the patient said back, and any questions]
When to call sooner: [Side effects, symptoms, or running out before the visit]

Approved by: [Prescriber name, credentials, date and time]
Note by: [Name, role, date and time]