How to Write an Effective Prescription Refill Request Note
A well-written prescription refill request note should assess the patient's current medication use patterns, evaluate for potential complications or uncontrolled symptoms, confirm maximization of non-opioid alternatives (when applicable), and document the clinical justification for continued therapy. 1
Essential Components to Document
Patient Assessment Elements
Before authorizing any refill, your note must address these specific clinical questions:
- Current medication usage pattern: Document whether the patient is taking the medication as prescribed, including specific doses and frequency of use 1
- Symptom control status: Assess whether the patient's underlying condition remains adequately controlled or if persistent symptoms suggest complications requiring evaluation 1
- Adherence verification: Confirm the patient received the previous prescription, document the start date, and verify the patient understands proper administration (with/without food, timing, etc.) 1
- Interval medication changes: Review any new prescription, over-the-counter, or herbal medications that could create drug interactions 1
Clinical Reasoning Documentation
Your note should clearly communicate your thought process:
- Problem-oriented approach: Identify the specific medical issue being treated and document current status with relevant findings 2
- Clinical justification: Explain why continued therapy is medically necessary rather than simply documenting the refill request 2
- Differential considerations: If the patient reports inadequate symptom control, document your assessment of whether this represents treatment failure, non-adherence, disease progression, or complications 1
Structured Note Format
Opening Statement
Begin with a clear, concise statement of the refill request and indication 2:
- Medication name (generic and brand)
- Current dose and frequency
- Indication for therapy
- Duration of current treatment
Assessment Section
Document your clinical evaluation 1:
- Medication reconciliation: Compare the patient's reported medication list against external sources (pharmacy records, prior documentation) 1
- Adherence assessment: Specifically document confirmation that the patient received the prescription, when they started it, and verification of proper use 1
- Toxicity monitoring: Review relevant laboratory tests and any adverse effects 1
- Alternative therapies: For pain medications specifically, document whether the patient is maximizing non-opioid agents including specific doses and frequency 1
Plan and Authorization
Clearly state your decision and rationale 2:
- Number of refills authorized
- Quantity per refill
- Any changes to dosing or frequency
- Follow-up plan and timing
- Patient education provided
Critical Pitfalls to Avoid
Common Documentation Errors
Do not simply document "refill requested" without clinical assessment 2. This fails to communicate your clinical reasoning and may not support medical necessity.
Avoid copy-paste from previous notes without updating 1, 2. This propagates outdated information and creates legal liability when clinical circumstances have changed.
Never omit the indication for therapy 3. Studies show pharmacies transcribe indications onto only 38% of labels when physicians include them on prescriptions, yet this information is critical for patient safety 3.
Special Considerations for Controlled Substances
For opioid refills specifically, additional documentation is required 1:
- Query prescription drug monitoring programs where available to identify other controlled substance prescriptions 1
- Document 24-hour pre-discharge opioid use for post-surgical patients, as those not using opioids in the 24 hours before discharge rarely require them afterward 1
- Assess for chronic pain: Patients with pre-existing opioid use or chronic pain syndromes may require consultation with their outpatient prescriber before refilling 1
Financial and Access Barriers
Document any financial concerns affecting adherence 1. Patients may not volunteer this information, but financial barriers are a common cause of non-adherence that requires assessment and intervention 1.
Consider prior authorization requirements 1. Note whether the medication requires pre-authorization to avoid delays in patient access 1.
Quality Standards for Refill Documentation
Your note should be 2:
- Brief but complete: An accurate synthesis of relevant findings and decision-making, not a verbatim transcript of the conversation 2
- Problem-focused: Clearly organized around the specific medication and indication 2
- Clinically relevant: Include pertinent positive and negative findings while avoiding "note bloat" with superfluous information 2
- Legally sound: Recognize that your documentation serves as a legal record that must be accurate and unaltered 2
Medication-Specific Details to Include
When documenting the prescription itself 1:
- Medication name (generic and brand)
- Dose, route, and frequency
- Start and end dates (if applicable)
- Reason for any discontinuation or changes
- All known allergies, intolerances, and adverse drug events 1
Follow-Up Documentation
Establish and document the follow-up plan 1. This should include:
- Timing of next clinical assessment
- Parameters that would prompt earlier contact
- Emergency and non-emergent contact information for the patient 1
- Plan for reassessment of continued need for therapy