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Draft a comprehensive differential diagnosis for acute substernal chest pain in a 45-year-old male with hypertension and hyperlipidemia, diaphoresis, exertional onset, and normal initial ECG/troponin; include life-threatening causes first, key distinguishing features, and immediate diagnostic next steps.

Draft a detailed differential diagnosis for new-onset unilateral throbbing headache with visual aura and brief monocular vision loss in a 32-year-old female on oral contraceptives; include red-flag symptoms, stroke/TIA considerations, and recommended initial workup.

Draft an assessment and plan for stage-2 hypertension (BP 162/98) in an obese 52-year-old with suspected obstructive sleep apnea; include ASCVD risk estimate, lifestyle prescriptions, first-line pharmacotherapy with drug/dose/targets, baseline labs/monitoring, and 4–6 week follow-up.

Draft an assessment and plan for type 2 diabetes follow-up with A1c 9.2% on metformin 1,000 mg BID and eGFR 65; compare adding a GLP-1 receptor agonist vs an SGLT2 inhibitor, address weight loss goals, hypoglycemia education, vaccinations, and micro/macrovascular screening.

Draft a history and physical for a patient presenting with chest pain, including HPI using OLDCARTS, pertinent ROS, PMH/meds/allergies, FH/SH, focused cardiac/pulmonary exam, initial labs and imaging orders, prioritized differential, HEART score risk stratification, and early management.

Draft a history and physical for a new patient with progressive exertional dyspnea, orthopnea, and bilateral leg edema; include differential (heart failure, COPD, PE, anemia, renal disease), targeted exam maneuvers, and first-line diagnostics and management.

Draft a progress note for COPD follow-up two weeks after an acute exacerbation treated with prednisone and antibiotics; include symptom trajectory, CAT score (if available), inhaler technique/adherence, oxygen needs, spirometry plan, smoking cessation counseling, and return precautions.

Draft a progress note for post-operative day 2 after total knee arthroplasty; include pain control strategy, DVT prophylaxis, PT/OT milestones, wound status, bowel/urinary function, labs/vitals review, complications screening, and discharge readiness.

Draft a discharge summary for community-acquired pneumonia admission; include admission/discharge dates, presenting symptoms, radiology/labs, pathogen if identified, inpatient therapies and response, discharge medications with durations, pending tests, follow-up appointments, and return precautions.

Draft a discharge summary for myocardial infarction managed with PCI and drug-eluting stent placement; include cath findings, complications, inpatient course, discharge medications (DAPT, statin, beta-blocker, ACEi/ARB), cardiac rehab referral, and follow-up plan.

Draft discharge instructions for a patient hospitalized with acute decompensated heart failure; include daily weights, sodium and fluid restriction amounts, medication list with dosing, signs of worsening heart failure, follow-up appointments, and lab monitoring plan.

Draft discharge instructions for an asthma exacerbation; include controller and reliever regimen, steroid taper schedule, spacer technique, trigger avoidance, a written asthma action plan, return precautions, and follow-up timing.

Draft a patient handout on managing high blood pressure in plain language; explain what BP numbers mean, key lifestyle steps (DASH diet, sodium limits, alcohol moderation), home BP monitoring instructions, medication adherence tips, and when to call the doctor.

Draft a patient handout for type 2 diabetes education in plain language; cover A1c goals, the plate method, physical activity targets, self-monitoring of blood glucose, hypoglycemia signs and the 15-15 rule, foot care basics, and a vaccination checklist.

Draft a summary of the latest CDC and WHO guidelines for managing community-acquired pneumonia in adults, including empiric antibiotic choices, duration of therapy, and follow-up recommendations.

Draft a plain-language overview of the ADA and AACE guidelines for diabetes management, focusing on A1c goals, weight management, and the use of GLP-1 receptor agonists and SGLT2 inhibitors.

Draft a summary of the 2024 USPSTF breast cancer screening recommendations, including updated screening intervals, risk-based approaches, and the role of MRI for high-risk patients.

Draft a concise summary of NCCN guidelines for melanoma management, including staging, surgical margins, adjuvant therapy, and checkpoint inhibitor recommendations.

Draft treatment alternatives for community-acquired MRSA skin infections in patients allergic to sulfa drugs; include oral and IV options, dosing, and duration.

Draft treatment alternatives for patients with type 2 diabetes who are unable to tolerate GLP-1 receptor agonists due to nausea; include medication substitutions and lifestyle recommendations.

Draft a summary of options for treating refractory depression, comparing ketamine infusions, transcranial magnetic stimulation (TMS), and electroconvulsive therapy (ECT).

Draft treatment options for advanced prostate cancer, including hormonal therapy, radiopharmaceuticals, and novel androgen receptor pathway inhibitors.

Draft a summary of recent research on mRNA vaccine technology beyond COVID-19, including applications in oncology and autoimmune disease prevention.

Draft an easy-to-understand overview of long COVID research, summarizing major symptoms, hypothesized mechanisms, and emerging treatment approaches.

Draft a summary of current research on Alzheimer’s disease biomarkers, including amyloid and tau imaging, and discuss how they influence diagnosis and trial design.

Draft an explanation of the interaction between warfarin and antibiotics such as ciprofloxacin or TMP-SMX, including INR effects and management recommendations.

Draft a summary evaluating drug interactions for patients taking Paxlovid and common cardiovascular drugs; include mechanism and recommended dose adjustments.

Draft a summary of the common and serious side effects of semaglutide, including GI intolerance, gallbladder disease, and thyroid-related warnings.

Draft an overview of potential side effects associated with long-term corticosteroid use, including osteoporosis, glucose intolerance, and adrenal suppression.

Draft a summary of essential lab tests to order in suspected acute pancreatitis, including amylase, lipase, liver enzymes, and metabolic panels, with interpretation guidance.

Draft laboratory workup recommendations for suspected hypothyroidism, including TSH, free T4, thyroid antibodies, and when to consider secondary causes.

Draft an explanation of which labs should be monitored in patients receiving methotrexate therapy, including CBC, LFTs, renal function, and frequency of monitoring.

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Course: Annual Prescription Renewal: Save Time and Improve Medication Adherence

CME Credits: 0.50

Released: 2014-10-23

How Will This Toolkit Help Me?
Learning Objectives
Summarize the process of annual synchronized prescription renewal
Identify advantages of utilizing annual synchronized prescription renewal
Describe the 3 key STEPS to effectively implement the annual synchronized prescription renewal process
Introduction
Annual prescription renewal refers to the process of renewing all of a patient's long-term medications once per year, for a duration of 12 to 15 months. Synchronized prescription renewal refers to the process of renewing all of a patient's long-term medications on the same date, resulting in fewer trips to the pharmacy, reduced risk of duplicate medications, and a lower likelihood of running out of medications. Ideally, both these processes occur, resulting in annual synchronized prescription renewal, which saves significant time for physicians and costs for practices.- Importantly, the frequency of patients' routine follow-up visits (eg, every 3 or 6 months) does not change when implementing annual synchronized prescription renewals.
How Much Time and Money Can You Save With Annual Synchronized Prescription Renewal?
Use this calculator to estimate the amount of time and money you could save each year by implementing an annual synchronized prescription renewal process in your practice. Calculations are for demonstration purposes only. Actual savings may vary.
Q&A
How much time and money per year will an annual synchronized prescription renewal process save my practice?
Consider a hypothetical scenario of an internal medicine practice that has not implemented an annual synchronized prescription renewal process. This practice has 1000 patients with chronic illness, with an average of 5 medications per patient. Every year, each patient makes an average of 2 calls per prescription. Each call lasts about 2 minutes. These factors result in more than 300 hours of physician and team member time spent on prescription renewals per year.
Three STEPS to Implement Annual Synchronized Prescription Renewals
Renew Prescriptions for the Maximum Duration Allowed By State Law
Synchronize All Prescriptions for Chronic Conditions to Be Renewed During One Yearly Visit
Include Instructions for the Pharmacy
STEP 1 Renew Prescriptions for the Maximum Duration Allowed By State Law
Start by renewing all medications for chronic illness for the maximum duration allowed by state law. In most states, the ; a handful of states allow renewal for up to 24 months. Ideally, this renewal will occur via a synchronized process during the (see STEP 2). When patients receive prescriptions for their chronic conditions for a full year, they will not need to call the office for refills, and they will not have any unanticipated gaps in .
Q&A
Should I only include patients seen once a year in the annual synchronized prescription renewal process?
Not necessarily. Patients are seen throughout the year as medically necessary. Medications are reviewed at each visit. Prescriptions may be modified and/or added. For consistency, prescriptions are written for 90 days with 4 refills. This way, you do not need to calculate the number of refills to last until the next annual comprehensive care visit because all prescriptions will be synchronized then.
How do I manage patients starting new medications that require close follow-up and/or modification, such as antihypertensives or antidepressants?
You are still following patients closely based on their medical needs. If their medication is modified, send a new prescription to the pharmacy along with a notification indicating that it replaces a previous prescription. No additional process is required if there are no changes and if the maximum number of refills were included in the initial prescription.
Suppose our practice uses prescription renewals as appointment reminders to encourage patients to come back for an interval visit. Will implementing an annual prescription renewal process lead to more “no shows”?
You can limit prescription refills to the number needed until the next appointment for the small subset of patients who do not comply with follow-up visits. Using an impending prescription expiration to encourage patients to keep their visits adds unnecessary work to a practice, contributes to patient and clinician stress, and often leads to .
What if pharmacies in my area don't honor prescriptions after 12 months?
Some states allow physicians to . If your state is not one of them, help patients “carry over” until their upcoming visit by scheduling their annual comprehensive care visit before the 1-year mark after the previous annual visit. This approach is the best way to minimize calls to the practice for medications in the interim. Setting up at the conclusion of this year's annual appointment can help.
Can I annually renew mail-order prescriptions?
Yes. Mail-order prescriptions should follow the same process as retail prescriptions.
STEP 2 Synchronize All Prescriptions for Chronic Conditions to Be Renewed During One Yearly Visit
The is an excellent time to renew all of a patient's long-term prescriptions because the medical history is thoroughly reviewed, including past and present conditions and medications.
During a busy workday, it may be tempting to renew only those medications that are due. However, renewing all prescriptions together and synchronizing the process reduces the subsequent number of calls for refills, saving significant time down the road. To do this, add a note to the pharmacist such as, “Renew these chronic meds for 1 year (90 x 4) and delete prior prescriptions for these meds. Please synchronize so they all come due the same day every 3 months.” Using a smartphrase will save even more time, so you don't need to write this for every patient.
A to this process is recommended (eg, a refill nurse or pends or prepares each renewal on the day of the annual visit). Streamlining this process eliminates the need to calculate the number of refills necessary to last the patient until the next . You can simply renew prescriptions for the maximum duration (ie, 90 days and 4 refills, or 90 x 4 in shorthand) to last the entire year.
Q&A
What happens if a medication has refills remaining at the time of the annual comprehensive care visit?
Having leftover refills does not change the approach. All prescriptions are renewed for the maximum duration whether they have refills left or not. A notation for the pharmacy that the new prescriptions replace the earlier prescriptions can be helpful. This is how all renewals become synchronized.
What happens if patients change pharmacies?
Pharmacies can often transfer prescriptions for non-controlled substances internally. The new pharmacy can then fill the remaining authorized refills. In many states, this process does not involve the physicians' office, and, if necessary, you can direct patients to coordinate prescription transfers themselves. If this is not possible, resending the medication may be necessary, but remember that this minority of patients will not counteract the overall time-saving benefits.
What about controlled substances?
You should not include prescriptions for controlled substances in the annual synchronized refill process. For tips on safely, effectively, and efficiently managing chronic pain, see the AMA STEPS Forward™ toolkit .
STEP 3 Include Instructions for the Pharmacy
Include instructions for the pharmacy on all prescription modifications and renewals as applicable. A standard notification indicating a medication discontinuation or a new dose replacing a previous one can accompany the electronic prescription submitted to the pharmacy. This notification allows the pharmacy to update the patient's current medication list, lessening the chance the patient will fill both the old and the new prescriptions.
You can also alert the pharmacy that the patient may not need to fill the renewed prescription right away to avoid dispensing the medication before the patient needs it.
Q&A
What about new prescriptions? My patients hate throwing pills away, so I usually give a 1-month supply for a new prescription and then ask the patient to call us for a 90-day supply once they know they tolerate the medication.
We suggest you write the prescription for 90 days plus 4 refills and add a note, “Please fill 1-month supply first time.” Writing the prescription this way allows the patient to get a smaller number of pills on the first fill while precluding the need for an extra call or fax to your office.
How can we best handle off-cycle prescription renewal requests after implementing the annual synchronized renewal process?
It will take up to 1 year to get all your patients into the annual synchronized prescription renewal cycle. After this, every prescription renewal request that could be synchronized but wasn't can be seen as a breakdown in the process and presents an opportunity to improve it. Despite all efforts in the prescription renewal process, there will still be renewal requests, and it is essential to have a strategy for managing them. Therefore, it is still necessary to to renew medications according to protocols and standing orders to reduce the physician's workload.
Conclusion
Annual synchronized prescription renewal can . To put this approach into action, use the STEP-by-STEP guide provided in this toolkit and the corresponding implementation checklist:
To understand the impact that synchronizing prescriptions can have on your practice, experiment with our interactive calculator, available in the Introduction section above and on its own page , or check out this downloadable guide for a more comprehensive measurement and assessment approach:
AMA Pearls
At a dedicated annual comprehensive care visit, renew all medications for chronic illnesses for the maximum duration allowed by state law.
Use a team-based approach to prepare or pend annual prescription renewals.
Include instructions for the pharmacy to help with synchronization.
Further Reading
Journal Articles and Other Publications
Sinsky CA, Rule A, Cohen G, et al. Metrics for assessing physician activity using electronic health record log data. J Am Med Inform Assoc. 2020;27(4):639-643. doi:
Farland B, Presutti J, Crowe S. Management of non-controlled prescription renewals in a primary care practice. American Association for Physician Leadership. November 29, 2019. Accessed December 1, 2021.
Pattin AJ, Devore N, Fowler J, Weldy D. An examination of the prescription renewal process and implications for primary care physicians and community pharmacists. J Pharm Pract. 2020;33(2):187-191. doi:
Nelson SD, Rector HH, Brashear D, et al. Rebuilding the standing prescription renewal orders. Appl Clin Inform. 2019;10(1):77-86. doi:
Doshi JA, Lim R, Li P, et al. Synchronized prescription refills and medication adherence: a retrospective claims analysis. Am J Manag Care. 2017;23(2):98-104.
Neuner JM, Fergestrom N, Laud PW, Pezzin L. Factors influencing prescription drug synchronization: the complex role of number of medications. J Manag Care Spec Pharm. 2019;25(6):714-718. doi:


Learning Objectives
1. Summarize the process of annual synchronized prescription renewal
2. Identify advantages of utilizing annual synchronized prescription renewal
3. Describe the 3 key STEPS to effectively implement the annual synchronized prescription renewal process


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