Chronic Hepatitis B Management Note

Visit date: [Date]   |   Patient name: [Full name]   |   Visit type: [Initial / Follow-up / Transfer-of-care]   |   Antiviral status: [On therapy / Off therapy / Considering initiation]

HBV Management Snapshot

HBsAg: [Positive / Negative / Unknown - obtain] — [Date]

HBeAg: [Positive / Negative / Unknown - obtain] — [Date]; anti-HBe: [Positive / Negative / Unknown - obtain] — [Date]

Most recent HBV DNA: [Value IU/mL — Date / Unknown - obtain]

Most recent ALT: [Value U/L — Date / Unknown - obtain]; ULN used: [Value and source]

Fibrosis assessment: [Method] — [Result] — [Date / Unknown - obtain]

Cirrhosis status: [Yes / No / Uncertain] — Evidence: [Objective findings / Unknown - obtain]

Current antiviral: [Drug, dose, start date / Not on therapy / Unknown - obtain]

HCC surveillance: Risk basis: [Risk basis] — Last imaging: [Modality — Date] — Next due: [Date / Unknown - obtain]

Coinfection testing: HIV: [Result — Date]; HCV: [Result — Date]; HDV: [Result / Not indicated — Date]

Subjective

[Reason for visit and interval events since last HBV-focused evaluation] (Include relevant symptoms such as fatigue, jaundice, RUQ pain; if cirrhotic, address decompensation signs; document medication adherence with barriers or side effects, alcohol use changes, immunosuppression exposure, and pregnancy status if applicable.)

HBV history (initial/transfer visits): [Diagnosis date, acquisition route, prior treatments and responses, known resistance, family history of HBV/cirrhosis/HCC] (Omit for routine follow-ups unless new information obtained.)

Objective

Vitals: [Relevant vitals if obtained]

Exam: [Pertinent liver-related findings: icterus, hepatosplenomegaly, ascites, edema, asterixis, mental status] (Document pertinent positives and negatives only.)

Labs: [HBV DNA, ALT/AST, bilirubin, INR, albumin, platelets, creatinine/eGFR as relevant] (Always include renal function if on or considering tenofovir.)

Trends:

• HBV DNA: [Date — Value]; [Date — Value]; [Date — Value]
• ALT: [Date — Value]; [Date — Value]; [Date — Value]

(List at least 3 timepoints when available; if fewer, note "Insufficient trend data" and when repeat testing is planned.)

Imaging/Staging: [Elastography/FIB-4/biopsy results with dates; HCC surveillance imaging with findings and LI-RADS if reported] (For calculated scores, label as "Calculated" and list inputs used.)

Assessment

Chronic hepatitis B

Phase determination: HBeAg: [Status — Date]; HBV DNA: [Value IU/mL — Date]; ALT: [Value U/L — Date — ULN: Value]; Fibrosis/cirrhosis: [Status with evidence]

Treatment criteria: [Immune-active hepatitis / Significant fibrosis ≥F2 / Cirrhosis / Family history HCC / Pregnancy prophylaxis / Immunosuppression] (List criteria met or not met.)

Eligibility conclusion: [Yes / No / Uncertain] — Rationale: [Specific justification] (Do not infer eligibility without documented criteria; specify what data are needed if uncertain.)

Additional problems

[Cirrhosis/portal hypertension status if applicable; HCC surveillance findings requiring follow-up; coinfections; metabolic or alcohol-related factors] (Include only problems requiring active management.)

Plan

HBV therapy

• Decision: [Continue / Start / Defer / Switch] — [Brief rationale]
• Regimen: [Drug, dose] (Include renal adjustment if applicable.)
• Monitoring: [HBV DNA/ALT interval; renal/bone monitoring if on tenofovir]
• Reassessment triggers: [Virologic breakthrough, ALT flare, adherence concerns]

HCC surveillance

• Risk basis: [Basis for eligibility]
• Modality/interval: [US ± AFP / CT / MRI] every [interval]
• Next due: [Date]
• Findings requiring action: [Recall imaging or diagnostic workup if applicable]

Other care

• Cirrhosis care: [Variceal screening, decompensation management if applicable]
• Coinfections: [HIV/HCV/HDV management if applicable]
• Preventive: [Hepatitis A vaccination status; transmission counseling: Provided / Reviewed, no changes]

Follow-up

• Return: [Timeframe]
• Pre-visit testing: [Labs and imaging to obtain before next visit]
• Pending safety-critical data: [List any missing elements: HBV DNA, ALT with ULN, cirrhosis determination, renal function on tenofovir, HCC surveillance timing]