Hepatology Discharge Summary (Cirrhosis/Chronic Liver Disease)

Facility/Service: [hepatology / transplant hepatology]

Admission Date: [Date]

Discharge Date: [Date]

Attending Physician: [Name, Credentials]

Primary Care Provider: [Name, Contact]

Outpatient Hepatologist/Transplant Center: [Name/Center] (Include only if applicable)

(For required sections with missing information, write "Unknown/Not available" with a brief reason. Omit conditionally relevant sections—Procedures, Consultations, Goals of Care—entirely if not applicable.)

Discharge Snapshot

[One-liner: age, sex, cirrhosis etiology, compensated vs decompensated status, severity score with date, and admission trigger]

Key inpatient events:

• [Event 1: procedure/complication treated and response]
• [Event 2]
• [Event 3]

(Include 2–5 key events; no sub-bullets)

Critical discharge dependencies:

• [Dependency 1: time-sensitive lab, procedure, surveillance, or referral with timeframe]
• [Dependency 2]
• [Dependency 3]

(Include 2–6 critical dependencies)

Reason for Hospitalization

[Brief narrative of reason for admission, precipitant(s) if known, and relevant context]

(2–6 sentences; precipitants may include infection, GI bleed, medication nonadherence, alcohol relapse, or other triggers)

Discharge Diagnoses

1. [Primary discharge diagnosis]
2. [Cirrhosis/chronic liver disease with etiology]
3. [Decompensation(s) during admission] (Include only those that materially affected care: ascites, hepatic encephalopathy, variceal bleeding, SBP, HRS-AKI, hepatic hydrothorax)
4. [HCC status] (Include if known or suspected)
5. [Portal vein thrombosis] (Include if present)
6. [Key comorbidities affecting management]

Hospital Course

(Organize by active problems, ordered by severity: life-threatening/unstable first, then decompensation management, then comorbidities. Include only relevant problem headings below; omit those not applicable to this admission.)

Cirrhosis severity and trajectory

• [Presentation/trigger and baseline status]
• [Severity indicators: MELD-Na and/or Child-Pugh with dates and values]
• [Inpatient course and clinical response]
• [Status at discharge]
• [Discharge plan, monitoring, and follow-up ownership]

Ascites/volume overload

• [Paracentesis: date(s), diagnostic vs therapeutic, cell count/albumin if diagnostic]
• [Diuretic strategy: agents, doses, changes]
• [SBP prophylaxis indication and status]
• [Clinical response: weight, abdominal girth, edema]
• [Discharge monitoring: daily weights, lab timing, diuretic hold parameters; follow-up ownership]

SBP/infection

• [Presentation and suspected source]
• [Paracentesis PMN count and culture results with dates]
• [Antibiotic regimen with start/stop dates]
• [Response to therapy]
• [Culture follow-up responsibility; long-term prophylaxis plan if indicated]

Hepatic encephalopathy

• [Precipitant(s) and mental status at presentation]
• [Therapies: lactulose regimen with target stools/day; rifaximin if used]
• [Clinical response and mental status at discharge]
• [Discharge plan: dosing targets, hydration guidance, safety counseling provided, follow-up ownership]

Varices/portal hypertensive bleeding

• [Presentation and hemodynamic status]
• [Endoscopy: date, findings, interventions]
• [Secondary prophylaxis plan: NSBB and/or repeat EVL schedule]
• [Supportive therapy: transfusions, octreotide, PPI if given]
• [Next EGD timing and scheduling responsibility]

AKI/HRS-AKI/electrolyte disorders

• [Diagnosis and staging]
• [Interventions: albumin, vasoconstrictors, diuretic adjustments, renal dosing]
• [Renal trajectory: peaks/nadirs and current values]
• [Discharge monitoring: lab timing, medication hold parameters, nephrology follow-up ownership]

Hepatocellular carcinoma

• [Known/suspected status and prior history]
• [Imaging: modality, date, key findings]
• [Tumor board/oncology input if obtained]
• [Surveillance or treatment plan with next due date and ownership]

Transplant evaluation

• [Referral/listing status]
• [Barriers or pending requirements]
• [MELD lab cadence and responsible service]
• [Next steps and transplant center contacts]

Nutrition/frailty

• [Assessment: sarcopenia, BMI, frailty metrics if available]
• [Inpatient interventions and counseling]
• [Discharge plan: protein targets, dietitian referral, supplements]

Etiology-directed therapy

• [Etiology and treatment status: alcohol use disorder care, viral hepatitis management, autoimmune/metabolic therapy]
• [Medications or counseling delivered]
• [Follow-up plan and ownership]

Pain management in cirrhosis

• [Analgesic strategy and rationale]
• [Avoidances noted: NSAIDs, maximum acetaminophen limit]
• [Opioid use: rationale, dosing, safety plan] (Include only if opioids prescribed)

Other comorbidities impacting care

• [Problem name and brief course]
• [Management and status at discharge]
• [Follow-up needs and ownership]

Procedures

(Include only if procedures were performed; otherwise omit this section entirely)

• [Date] — [Procedure]: [Indication]; [Key findings]; [Complications]; [Follow-up needs]
• [Date] — [Procedure]: [Indication]; [Key findings]; [Complications]; [Follow-up needs]

Key Results

• Labs ([date]): Hgb [value], Plt [value], Na [value], K [value], Cr [value], T.bili [value], Albumin [value], INR [value]
• MELD-Na ([date]): [value]
• Significant trends: [sodium nadir, peak creatinine, other actionable trends] (Include only if clinically actionable)
• Actionable imaging ([modality, date]): [Key findings and required follow-up] (Include only studies with follow-up implications: HCC surveillance, portal vein thrombosis, TIPS patency)

Consultations

(Include only if consulting services were involved; otherwise omit this section entirely)

• [Service]: [Actionable discharge recommendations; pending items if any]
• [Service]: [Actionable discharge recommendations; pending items if any]

Condition at Discharge

• Clinical stability: [Stable for discharge / Improved / Other status]
• Pertinent exam: [Ascites/edema status, mentation, jaundice]
• Functional status: [Mobility and activity level]
• Devices: [Drains, PICC, supplemental oxygen, other] (Include only if present)

Disposition and Services

Disposition: [Destination and level of care]

Services arranged: [Home health, PT, OT, infusion services, DME, or "No services required"]

Allergies

[Medication allergies with reaction types, or "No known drug allergies"]

Discharge Medications

• [Medication] — [dose] [route] [frequency] — [indication] — [stop date] (Include stop date only for time-limited therapies)
• [Medication] — [dose] [route] [frequency] — [indication]
• [Medication] — [dose] [route] [frequency] — [indication]

Medication reconciliation summary:

• Started: [New medications with reasons]
• Stopped: [Medications stopped with reasons]
• Dose changed: [Old dose → New dose with reasons]
• Held: [Medications held with restart criteria and decision owner]

Medication safety parameters:

• Diuretics: Hold if [hypotension threshold], [renal function criteria], or [hyponatremia threshold]
• Lactulose: Target [number] stools/day; reduce if dehydration or excessive diarrhea; ensure adequate hydration
• Nonselective beta-blocker: Hold if symptomatic hypotension, HR below [threshold], AKI, or severe hyponatremia (Include only if NSBB prescribed)
• Acetaminophen: Do not exceed [max dose] per 24 hours
• NSAIDs: Avoid — renal and bleeding risk in cirrhosis

Diet, Activity, and Self-Management

• Diet: [Sodium restriction if prescribed]; [Protein goal if addressed]; [Fluid restriction with amount] (Include fluid restriction only if specifically ordered)
• Activity: [Activity level and precautions]
• Daily monitoring: [Weights, bowel movement tracking, mental status checks by family/caregiver] (Include only if part of discharge plan)

Return Precautions

Return to the emergency department or call the clinic immediately for:

• Fever, new or worsening abdominal pain, or signs of infection
• Black or bloody stools, vomiting blood, or significant bleeding
• New or worsening confusion, excessive sleepiness, or difficulty waking
• Inability to take medications, persistent vomiting, or signs of dehydration
• Rapid weight gain (>2–3 lbs/day), increasing abdominal size, or worsening leg swelling
• Worsening shortness of breath or chest pain
• Severe weakness, lightheadedness, or painful muscle cramps

Contact: [Clinic/Service name and phone]; [After-hours instructions]

Follow-Up Appointments

• Hepatology: [Location] — [Date/time or timeframe] — [Purpose]
• Primary care: [Location] — [Date/time or timeframe] — [Purpose]
• [Other specialty]: [Location] — [Date/time or timeframe] — [Purpose]

Pending Results

• [Test name] — obtained [date]; Responsible: [clinician/service]; Action: [call patient / review at visit / send to PCP] within [timeframe]
• [Test name] — obtained [date]; Responsible: [clinician/service]; Action: [call patient / review at visit / send to PCP] within [timeframe]

(If none, state: "No pending results at discharge.")

Planned Post-Discharge Studies

• Labs: [Panel] — [timing]; Responsible: [clinician/service]
• Imaging: [Modality and indication] — due [date/window]; Responsible: [clinician/service]
• Endoscopy: [Indication] — [timing]; Responsible: [clinician/service]

Surveillance and Longitudinal Care Plan

• HCC surveillance: [Modality] — Next due [date]; Responsible: [clinician/service]
• Variceal surveillance: Last EGD [date]; Next due [date/interval]; Prophylaxis: [NSBB / banding / both]
• Vaccinations: [Updated during admission / Still due: list]; [Next steps]
• Nutrition: [Dietitian referral status and goals] (Include if applicable)
• Etiology-directed therapy: [Plan and ownership]
• Transplant pathway: [Referral/listing status]; [MELD lab cadence]; Responsible: [service]

Goals of Care

(Include only if goals of care were addressed during admission; otherwise omit this section entirely)

• Code status: [Full code / DNR / DNI / DNR-DNI / Other]
• Surrogate decision maker: [Name and contact]
• Palliative care: [Involvement and recommendations]
• Hospice: [Status if applicable]