Alcohol-Associated Liver Disease Visit Note

Date: [Date]

Patient: [Patient name or identifier]

Encounter Type: [new consult / follow-up]; [clinic / telehealth]

Provider: [Provider name and credentials]

Referral Source: [Referring clinician/service] (Include for new consults only)

Clinical Summary

• [ALD phenotype and stage] (e.g., steatosis, steatohepatitis, alcohol-associated cirrhosis [compensated / decompensated])
• [Key complications] — [active vs controlled status]
• [Current alcohol status] — Last drink: [explicit date / not assessed today]; [abstinent / ongoing use / return to use]
• [Severity] — MELD: [value] (labs dated [date]); Child-Pugh: [class/score] (if cirrhosis)
• [Transplant status] — [not referred / referred / evaluating / listed / post-transplant]

History of Present Illness

[Reason for visit and interval history] (Narrative of why the patient is being seen today and changes since last hepatology contact. Include hospitalizations, procedures, decompensation events, infections, and medication changes with explicit dates.)

[Liver-related symptoms] (Presence/absence and severity of jaundice, abdominal distension, edema, GI bleeding symptoms, confusion or sleep–wake reversal, nutrition/weight changes.)

[Alcohol use history — explicitly date-anchored] (Use person-first, non-stigmatizing language. Do not infer status. If unknown, state "not assessed today" rather than omitting.)

• Last drink: [MM/DD/YYYY / not assessed today]
• Current pattern: [quantity in standard drinks; frequency / abstinent / not assessed today]
• AUD status: [no AUD / mild / moderate / severe / not assessed today]
• Treatment engagement: [none / counseling / mutual support / pharmacotherapy] with details if applicable
• Withdrawal history: [none / uncomplicated / prior seizure(s) / prior delirium tremens / not assessed today]

[Transplant discussion] (Include when relevant. Summarize evaluation stage, patient understanding, goals, and concerns. Frame candidacy as multidisciplinary assessment rather than absolute abstinence duration requirements.)

Objective

Vitals: [BP, HR, RR, Temp, SpO2, Weight as relevant] (For telehealth, label patient-reported values.)

Exam: [General appearance]; [jaundice/icterus]; [abdominal findings including distension, fluid wave, tenderness]; [asterixis present/absent]; [peripheral edema]; [stigmata of chronic liver disease]. (For telehealth, document limitations and observable elements.)

Labs/Imaging: [Key liver panel with dates: TBili, INR, Albumin, AST, ALT, Platelets, Creatinine, Sodium — note trends if significant]; [Relevant imaging findings with dates]; [Elastography if available]; [Alcohol biomarkers (PEth/EtG) if obtained — document discordance with self-report neutrally as requiring follow-up]

Severity Scores: MELD [value] (labs dated [date]); Child-Pugh [class/score] if cirrhosis. (For recent alcohol-associated hepatitis, include Maddrey DF and/or Lille score with dates if applicable.)

Assessment and Plan

[Brief synthesis] (2–3 sentences: ALD stage, current alcohol status, severity trajectory, and immediate priorities.)

ALD/Cirrhosis

Assessment: [Phenotype and stage]; [alternate etiologies considered]; [complications status]; [nutritional status]

Plan: [Abstinence as primary disease-modifying intervention — document discussion and patient preferences]; [Diagnostics and monitoring: labs, imaging, HCC surveillance with next due date]; [Complications management: ascites/diuretics, varices/beta-blocker and EGD status, hepatic encephalopathy regimen as applicable]; [Nutrition goals and supplementation]; [Vaccinations if indicated]; [Follow-up timing and return precautions]

AUD

Assessment: [Current status: abstinent / ongoing use / return to use]; [AUD severity]; [treatment engagement]; [withdrawal risk]

Plan: [Agreed treatment goal with patient preferences documented]; [Behavioral interventions: counseling, mutual support, referrals]; [Pharmacotherapy plan tailored to liver/renal function, or rationale if deferred]; [Relapse mitigation: triggers, coping strategies, follow-up cadence]; [Care coordination: addiction medicine, social work, psychiatry as applicable]

Transplant Pathway

(Include when decompensation, rising MELD, or patient inquiry is present.)

Assessment: [Current status]; [key barriers and facilitators]; [readiness and support system]

Plan: [Referral or evaluation steps]; [Monitoring strategy]; [Coordination with transplant center]. (Frame candidacy as multidisciplinary assessment incorporating clinical, psychosocial, and recovery supports.)

Follow-Up

• [Next hepatology visit timing]
• [Interim labs/imaging schedule]
• [Contingency instructions: when to call clinic vs present to ED]

(Documentation note: For high-value ALD data elements — last drink date, AUD treatment status, transplant status — explicitly document as "unknown," "not assessed today," or "not applicable" rather than omitting. Do not infer abstinence or AUD remission from appearance or lab trends alone. Maintain neutral, person-first language throughout.)