Refill note

Telephone Medication Refill Request
[date name="date2" default="timestamp"] central time

Name: [text name="patient_name" memo="Enter patient name" size="10"]

Patient [var name="patient_name"] contacted the clinic requesting a refill of medications for ongoing management of their condition. The patient reports stable symptoms and wishes to continue the current treatment regimen. A face-to-face consultation was declined.

[var name="patient_name"] reports [select name="adherence" value="consistent use without side effects|consistent use with manageable side effects|inconsistent use - specify reasons|not applicable as new prescription"].

The medication refill request for [var name="patient_name"] has been reviewed following a thorough examination of their medical history and chart notes. The following medications have been authorized for refill and a prescription has been sent to the patient's preferred pharmacy:

[select name="prescription1"  value="|Adderall XR 10 mg as needed per day|Adderall XR 15 mg as needed per day|Adderall XR 20 mg as needed per day|Adderall XR 25 mg as needed per day|Adderall XR 30 mg as needed per day|Adderall XR 5 mg as needed per day|Azstarys 26.1 mg as needed per day|Azstarys 39.2 mg as needed per day|Azstarys 52.3 mg as needed per day|Dyanavel XR 10 mg as needed per day|Dyanavel XR 15 mg as needed per day|Dyanavel XR 20 mg as needed per day|Intuniv 1mg daily|Intuniv 2mg daily|Intuniv 3mg daily|Intuniv 4mg daily|Kapvay 0.1mg daily|Kapvay 0.2mg daily|Prazosin 1mg at bedtime|Prazosin 2mg at bedtime|Prazosin 3mg at bedtime|Prazosin 4mg at bedtime|Qelbree 100mg daily|Qelbree 150mg daily|Qelbree 200mg daily|Qelbree 200mg daily for 14 days|Rexulti 0.5 mg daily|Rexulti 1 mg daily|Rexulti 2 mg daily|Rexulti 3 mg daily|Rexulti 4 mg daily|Ritalin LA 10 mg as needed per day|Ritalin LA 20 mg as needed per day|Ritalin LA 30 mg as needed per day|Ritalin LA 40 mg as needed per day|Strattera 10mg daily|Strattera 18mg daily|Strattera 25mg daily|Strattera 25mg daily for 7 days then 40mg daily|Strattera 40mg daily|Strattera 60mg daily|Trazodone 25-50mg at bedtime as needed for insomnia|Trazodone 25mg at bedtime as needed for insomnia|Trazodone 50-100mg at bedtime as needed for insomnia|Trazodone 50mg at bedtime as needed for insomnia|Trintellix 5 mg daily|Trintellix 10 mg daily|Trintellix 15 mg daily|Trintellix 20 mg daily|Vistaril 10 mg as needed for anxiety|Vistaril 10-20 mg as needed for anxiety|Vistaril 20 mg as needed for anxiety|Vistaril 25 mg as needed for anxiety|Vyvanse 10 mg as needed per day|Vyvanse 20 mg as needed per day|Vyvanse 30 mg as needed per day|Vyvanse 40 mg as needed per day|Vyvanse 50 mg as needed per day|Vraylar 1.5 mg every evening|Vraylar 3 mg every evening|Vraylar 4.5 mg every evening|Vraylar 6 mg every evening|Wellbutrin XL 150 mg daily|Wellbutrin XL 300 mg daily"]
[select name="prescription2"  value="|Adderall XR 10 mg as needed per day|Adderall XR 15 mg as needed per day|Adderall XR 20 mg as needed per day|Adderall XR 25 mg as needed per day|Adderall XR 30 mg as needed per day|Adderall XR 5 mg as needed per day|Azstarys 26.1 mg as needed per day|Azstarys 39.2 mg as needed per day|Azstarys 52.3 mg as needed per day|Dyanavel XR 10 mg as needed per day|Dyanavel XR 15 mg as needed per day|Dyanavel XR 20 mg as needed per day|Intuniv 1mg daily|Intuniv 2mg daily|Intuniv 3mg daily|Intuniv 4mg daily|Kapvay 0.1mg daily|Kapvay 0.2mg daily|Prazosin 1mg at bedtime|Prazosin 2mg at bedtime|Prazosin 3mg at bedtime|Prazosin 4mg at bedtime|Qelbree 100mg daily|Qelbree 150mg daily|Qelbree 200mg daily|Qelbree 200mg daily for 14 days|Rexulti 0.5 mg daily|Rexulti 1 mg daily|Rexulti 2 mg daily|Rexulti 3 mg daily|Rexulti 4 mg daily|Ritalin LA 10 mg as needed per day|Ritalin LA 20 mg as needed per day|Ritalin LA 30 mg as needed per day|Ritalin LA 40 mg as needed per day|Strattera 10mg daily|Strattera 18mg daily|Strattera 25mg daily|Strattera 25mg daily for 7 days then 40mg daily|Strattera 40mg daily|Strattera 60mg daily|Trazodone 25-50mg at bedtime as needed for insomnia|Trazodone 25mg at bedtime as needed for insomnia|Trazodone 50-100mg at bedtime as needed for insomnia|Trazodone 50mg at bedtime as needed for insomnia|Trintellix 5 mg daily|Trintellix 10 mg daily|Trintellix 15 mg daily|Trintellix 20 mg daily|Vistaril 10 mg as needed for anxiety|Vistaril 10-20 mg as needed for anxiety|Vistaril 20 mg as needed for anxiety|Vistaril 25 mg as needed for anxiety|Vyvanse 10 mg as needed per day|Vyvanse 20 mg as needed per day|Vyvanse 30 mg as needed per day|Vyvanse 40 mg as needed per day|Vyvanse 50 mg as needed per day|Vraylar 1.5 mg every evening|Vraylar 3 mg every evening|Vraylar 4.5 mg every evening|Vraylar 6 mg every evening|Wellbutrin XL 150 mg daily|Wellbutrin XL 300 mg daily"]
[select name="prescription3" value="|Adderall XR 10 mg as needed per day|Adderall XR 15 mg as needed per day|Adderall XR 20 mg as needed per day|Adderall XR 25 mg as needed per day|Adderall XR 30 mg as needed per day|Adderall XR 5 mg as needed per day|Azstarys 26.1 mg as needed per day|Azstarys 39.2 mg as needed per day|Azstarys 52.3 mg as needed per day|Dyanavel XR 10 mg as needed per day|Dyanavel XR 15 mg as needed per day|Dyanavel XR 20 mg as needed per day|Intuniv 1mg daily|Intuniv 2mg daily|Intuniv 3mg daily|Intuniv 4mg daily|Kapvay 0.1mg daily|Kapvay 0.2mg daily|Prazosin 1mg at bedtime|Prazosin 2mg at bedtime|Prazosin 3mg at bedtime|Prazosin 4mg at bedtime|Qelbree 100mg daily|Qelbree 150mg daily|Qelbree 200mg daily|Qelbree 200mg daily for 14 days|Rexulti 0.5 mg daily|Rexulti 1 mg daily|Rexulti 2 mg daily|Rexulti 3 mg daily|Rexulti 4 mg daily|Ritalin LA 10 mg as needed per day|Ritalin LA 20 mg as needed per day|Ritalin LA 30 mg as needed per day|Ritalin LA 40 mg as needed per day|Strattera 10mg daily|Strattera 18mg daily|Strattera 25mg daily|Strattera 25mg daily for 7 days then 40mg daily|Strattera 40mg daily|Strattera 60mg daily|Trazodone 25-50mg at bedtime as needed for insomnia|Trazodone 25mg at bedtime as needed for insomnia|Trazodone 50-100mg at bedtime as needed for insomnia|Trazodone 50mg at bedtime as needed for insomnia|Trintellix 5 mg daily|Trintellix 10 mg daily|Trintellix 15 mg daily|Trintellix 20 mg daily|Vistaril 10 mg as needed for anxiety|Vistaril 10-20 mg as needed for anxiety|Vistaril 20 mg as needed for anxiety|Vistaril 25 mg as needed for anxiety|Vyvanse 10 mg as needed per day|Vyvanse 20 mg as needed per day|Vyvanse 30 mg as needed per day|Vyvanse 40 mg as needed per day|Vyvanse 50 mg as needed per day|Vraylar 1.5 mg every evening|Vraylar 3 mg every evening|Vraylar 4.5 mg every evening|Vraylar 6 mg every evening|Wellbutrin XL 150 mg daily|Wellbutrin XL 300 mg daily"]
[text name="other_meds" memo="Specify any additional medications" default=" "]

[var name="patient_name"]'s prescription refill request has been addressed. Medication adherence and tolerability have been reviewed to ensure continued appropriateness of therapy. The refill has been sent to  [var name="patient_name"] 's preferred pharmacy. Follow-up select  [select name="follow_up_interval" value="In 4 weeks|In 2 weeks|In 3 months|In 6 months"].
Visit modality for follow-up:[select name="visit_modality" value="In-person or Telehealth|In-person|Telehealth"] has been recommended to monitor ongoing efficacy and safety. [var name="patient_name"] has been instructed to report any new or worsening symptoms immediately.
Telephone Medication Refill Request
central time

Name: Enter patient name

Patient patient_name contacted the clinic requesting a refill of medications for ongoing management of their condition. The patient reports stable symptoms and wishes to continue the current treatment regimen. A face-to-face consultation was declined.

patient_name reports .

The medication refill request for patient_name has been reviewed following a thorough examination of their medical history and chart notes. The following medications have been authorized for refill and a prescription has been sent to the patient's preferred pharmacy:




Specify any additional medications

patient_name's prescription refill request has been addressed. Medication adherence and tolerability have been reviewed to ensure continued appropriateness of therapy. The refill has been sent to patient_name 's preferred pharmacy. Follow-up select .
Visit modality for follow-up: has been recommended to monitor ongoing efficacy and safety. patient_name has been instructed to report any new or worsening symptoms immediately.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.78, 15 form elements, 134 boilerplate words, 2 text boxes, 1 dates, 6 drop downs, 6 variables, 9 total clicks
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