Cirrhosis Management Note (Decompensated)

Date/Time: [Encounter date and time]

Patient: [Name, DOB, MRN]

Provider: [Clinician name, credentials, role]

Encounter Type: [Outpatient follow-up / Inpatient progress / Consult] — [Service]

Cirrhosis Dashboard

• Etiology: [Primary etiology] — [Etiologic therapy: active / complete / not indicated / unknown] (If unknown, state what information is missing and what was requested.)
• MELD-Na: [Calculated value] ([Date]) — Na [value], Cr [value], Tbili [value], INR [value] (If unknown, specify missing component and action ordered.)
• Child-Pugh: [Class A/B/C] ([Date]) — Tbili [value], Alb [value], INR [value], Ascites [grade], HE [grade] (If unknown, specify missing component and action ordered.)
• Decompensation History: [List only events that occurred with dates: ascites, variceal bleed, HE, SBP, HRS/AKI]
• Complication Status:
  • Ascites: [none / mild / moderate / tense] — [diuretic regimen or status] — [paracentesis plan if applicable]
  • HE: [none / intermittent / persistent] — [lactulose dose, stool goal status] — [rifaximin: on/off]
  • Variceal prophylaxis: [NSBB agent/dose or not on NSBB] — [Last EGD date and findings]
  • SBP prophylaxis: [agent / not indicated / indicated but not on]
  • Renal: [Creatinine trend with date] (Note if AKI/HRS suspected.)
  • Transplant: [referred / listed / eval in progress / not a candidate with reason / patient preference]
• HCC Surveillance: [Last imaging modality and date] — [Next due date] (Note if overdue and action ordered.)

Subjective

Interval history: [Hospitalizations, ED visits, procedures (paracentesis dates/volumes, EGD, imaging), infections, medication changes since last encounter] (Include only events that occurred.)

Symptoms by domain:

• Volume: [Weight change with timeframe, distension, edema, dyspnea]
• Encephalopathy: [Confusion, sleep-wake reversal, falls, safety concerns] (Use direct quotes for safety events.)
• Bleeding: [Melena, hematemesis, lightheadedness, transfusions]
• Infection: [Fever, abdominal pain, peritonitis symptoms]
• Renal: [Urine output changes, nephrotoxin exposure]
• Nutritional/functional: [Appetite, protein intake, falls, ADLs]

Medication reconciliation:

• Diuretics: [Agent(s), dose(s), adherence, side effects]
• Lactulose: [Dose] — [Stool goal achieved: yes/no] — [Barriers]
• Rifaximin: [On/off, adherence]
• NSBB: [Agent/dose, tolerance]
• SBP prophylaxis: [Agent/dose, indication]
• High-risk meds: [NSAIDs, benzodiazepines, opioids, sedatives, nephrotoxins — document presence/absence and action taken]

Objective

Vitals: BP [value], HR [value], SpO2 [value], Weight [today] vs [prior weight and date] (Include orthostatics only if symptomatic.)

Exam: [Mental status and asterixis if relevant] [Ascites grade] [Peripheral edema] [Signs of GI bleed or infection if suspected] (Document only pertinent cirrhosis-focused findings.)

Labs ([Date]): Na [value], K [value], Cr [value], Tbili [value], Alb [value], INR [value], Hgb [value], Plt [value] [Other clinically indicated studies: ammonia, cultures, etc.] (If unavailable, state date of last data and what was ordered. Do not present outdated values as current.)

Data:

• Imaging: [Modality, date, key findings]
• EGD: [Date, varices findings, interventions, next interval]
• Paracentesis: [Date, PMN count, culture, SAAG if applicable]

Assessment & Plan

Global statement: [Etiology] with [current decompensation phenotype(s)]. MELD-Na [value], Child-Pugh [class]. Goals: [Transplant-eligible with status / Supportive care focus].

(Document each active complication below. For stable or absent complications, include only a brief status line.)

Ascites

Status: [One-line summary with trajectory]. Data: [Weights, exam grade, recent paracenteses, sodium, creatinine].

Plan: [Diuretic regimen and adjustments] [Paracentesis plan with albumin replacement] [Sodium guidance] [Monitoring with timing] [Patient education].

Spontaneous Bacterial Peritonitis

Status: [History or current suspicion]. Data: [PMN/culture results with dates].

Plan: [Treatment if active] [Prophylaxis indication and agent] [Follow-up taps if indicated] [Return precautions].

Hepatic Encephalopathy

Status: [One-line summary]. Data: [Mental status, asterixis, precipitating factors].

Plan: [Lactulose titration to stool goal] [Rifaximin] [Trigger mitigation] [Safety counseling] [Monitoring].

Varices / Portal Hypertension

Status: [One-line summary]. Data: [Last EGD findings, banding history, bleeding history].

Plan: [NSBB initiation/titration or hold rationale] [EGD surveillance or therapeutic plan with timing].

Renal Function / HRS Risk

Status: [Creatinine trend and context]. Data: [Urinalysis, volume status, exposures].

Plan: [Nephrotoxin avoidance] [Volume management] [If HRS considered, document criteria met or state "suspected—workup ongoing"] [Escalation criteria].

Nutrition / Frailty

Status: [Appetite, weight trend, sarcopenia, functional status].

Plan: [Protein and caloric targets] [Bedtime snack] [Dietician referral] [Exercise/PT] [Monitoring].

Transplant

Status: [Referred / Listed / Evaluation in progress / Not a candidate].

Plan: [Next steps, required testing, optimization] (If not a candidate, specify: medical contraindication, transplant center decision, or patient preference.)

HCC Surveillance

Status: [Eligible: yes/no with reason]. Data: [Last imaging date/modality and result].

Plan: [Next due date] [Orders placed] [Recall plan for lesions].

Follow-up

• Orders: [Labs, imaging, procedures with indications]
• Referrals: [Transplant center, dietician, PT, addiction medicine, social work as relevant]
• Next visit: [Interval] — [Prerequisites to complete before return]