Hepatology Initial Consultation Note (Outpatient)

Date/Time: [Date and time of encounter]

Encounter Type: Initial Outpatient Hepatology Consultation

Clinic Site: [Clinic location]

Referring Clinician: [Name and specialty]

History Sources: [patient / family / outside records / interpreter]

Reason for Consultation

[Referral question] (Capture verbatim when available. Examples: elevated liver enzymes, hepatic steatosis, chronic viral hepatitis, cirrhosis management, cholestasis workup, abnormal liver imaging.)

History of Present Illness

[Onset and time course of liver issue] (State when abnormal labs or imaging were first noted, or symptom onset if applicable, and describe trajectory.)

[Current liver-related symptoms or explicit absence of symptoms] (Integrate: jaundice, dark urine, pruritus, abdominal distension, lower extremity edema, confusion or sleep-wake reversal, GI bleeding signs, easy bruising, RUQ pain, fevers, weight loss, fatigue.)

[Summary of prior evaluation with dates] (Lab pattern: hepatocellular vs cholestatic vs mixed; serologies and autoimmune/metabolic testing performed; key imaging findings; elastography results if available; prior liver biopsy summary.)

[Prior liver-directed treatments and response] (Medications, lifestyle interventions, antiviral therapy, endoscopic therapies; include dates and outcomes.)

Liver Risk Factors

(Use Present/Absent/Unknown designations for each domain. Quantify where relevant. If a required domain is not assessed, state this explicitly rather than omitting.)

• Metabolic: [BMI, diabetes/prediabetes status, dyslipidemia, hypertension, OSA, weight trajectory and max adult weight, dietary pattern and activity level]
• Alcohol (required, quantified): [Current use: type, quantity in standard drinks per day/week, frequency, binge pattern] [Past heavy use: duration, peak intake] [Last drink date] [Prior treatment or withdrawal history] [If abstinent: start date]
• Viral hepatitis risks (required): [Injection or intranasal drug use, tattoos/piercings, needlestick exposures, transfusions before early 1990s, incarceration history, sexual risk factors, birth in endemic area, household contacts with hepatitis]
• Medications/supplements/toxins (required): [Current and recent prescription medications, OTC use including acetaminophen dosing pattern, herbals and dietary supplements, occupational or chemical exposures] (Flag potential hepatotoxins and anticoagulants/antiplatelets.)
• Autoimmune/cholestatic associations: [Personal or family autoimmune disease, IBD, sicca symptoms, thyroid disease]
• Genetic/metabolic clues: [Family history of cirrhosis or early liver cancer, iron overload, early emphysema, neuropsychiatric symptoms in young adults suggesting Wilson disease]

Past Medical History

• [Key comorbidities with onset year if known] (Emphasize: DM, CKD, heart failure, IBD, HIV, prior malignancies.)

Past Surgical History

• [Relevant procedures with dates] (Emphasize: abdominal/bariatric surgery, cholecystectomy, ERCP/EUS, prior EGD with variceal findings, colonoscopy if PSC/IBD context, liver biopsy with indication and key pathology.)

Medications

[Reconciled medication list including prescriptions, OTCs, vitamins, supplements, herbals with dose and frequency] (Mark potential hepatotoxins and anticoagulants/antiplatelets. If reconciliation incomplete, state limitation.)

Allergies

• [Allergen] — [reaction type: anaphylaxis / rash / intolerance / other]

Family History

• [Liver disease, cirrhosis, HCC, iron overload, autoimmune conditions in relatives with relationship and age at diagnosis if known]

Social History

• Tobacco: [status and pack-years]
• Occupation: [role and relevant exposures]
• Social factors affecting adherence: [housing, food security, supports] (Include if relevant; alcohol and substance use details may reference Liver Risk Factors section.)

Review of Systems

(Focused ROS; avoid exhaustive multi-system review unless clinically warranted.)

• Constitutional: [fevers, chills, weight loss, fatigue]
• GI: [abdominal pain, nausea, vomiting, bowel habits, GI bleeding signs]
• Skin: [pruritus, rash, jaundice]
• Neuropsychiatric: [confusion, sleep-wake reversal, mood or cognitive changes]
• Bleeding/bruising: [epistaxis, gum bleeding, easy bruising]

Vitals

BP: [value]   HR: [value]   Weight: [value]   BMI: [value]   O2 Sat: [value]

Physical Examination

(Document only systems actually examined; avoid auto-populated normals.)

• General: [appearance, nutritional status, sarcopenia, distress]
• Skin: [jaundice, excoriations, spider angiomas, palmar erythema]
• Abdomen: [hepatomegaly, splenomegaly, ascites assessment including shifting dullness or fluid wave if performed, tenderness]
• Extremities: [edema]
• Neurologic: [mental status, asterixis] (Include if encephalopathy concern.)

Data Reviewed

(Include dates and sources for all referenced results.)

Laboratories

• Liver chemistries: [AST, ALT, alkaline phosphatase, total/direct bilirubin with values, dates, sources]
• Synthetic function: [albumin, INR with values, dates, sources]
• Hematology: [platelets, CBC trends with values, dates, sources]
• Renal/electrolytes: [creatinine, sodium with values, dates, sources] (Include if cirrhosis suspected.)
• Viral serologies: [HBsAg, anti-HBc, anti-HBs, HCV Ab/RNA, HAV IgG with dates, sources]
• Autoimmune/metabolic markers: [ANA, ASMA, AMA, IgG, ferritin, transferrin saturation, ceruloplasmin, A1AT as relevant with dates, sources]

Imaging

[Modality: RUQ ultrasound / CT / MRI / MRCP / Doppler] — [date, source, key findings]

Elastography

Test type: [VCTE / MRE / SWE]   Date: [date]   Source: [internal / external]

Liver stiffness: [value with units]   Quality metrics: [IQR/median, success rate]   CAP: [value] (if VCTE)

Potential confounders: [acute inflammation, cholestasis, hepatic congestion, recent heavy alcohol use] (Note if present.)

Calculated Scores

• FIB-4: [value] — Inputs: Age [value], AST [value], ALT [value], Platelets [value] with dates — Category: [low / indeterminate / high]
• APRI: [value] — Inputs: AST [value], ULN AST [value], Platelets [value] with dates (Include if calculated.)
• MELD-Na: [value] — Inputs: Bilirubin [value], INR [value], Creatinine [value], Sodium [value] with dates (Include if cirrhosis suspected.)
• Child-Pugh: [class and score] — Inputs: Bilirubin [value], Albumin [value], INR [value], Ascites [grade], Encephalopathy [grade] (Include if cirrhosis suspected.)

Assessment

[One-sentence case summary] (Include: patient demographics, primary liver issue, most likely etiology using uncertainty language such as "suggestive of" or "consistent with" for provisional diagnoses, fibrosis stage if known, key supporting evidence.)

Problem List

(Prioritize by severity and actionability. For each problem, document supporting evidence with dates and differential if uncertainty exists.)

1. [Primary liver diagnosis or leading diagnostic category]: [Assessment summary with evidence and dates; differential if uncertain]
2. [Fibrosis stage or cirrhosis status]: [no evidence of advanced disease / possible compensated advanced chronic liver disease / known cirrhosis] — Supporting evidence: [platelets, elastography, imaging signs, clinical signs with dates]
3. [Portal hypertension status]: [Current assessment and varices risk] (Include if advanced disease suspected.)
4. [Additional problems as applicable]: [Ascites, hepatic encephalopathy, HCC risk, metabolic comorbidities, alcohol use disorder, medication safety concerns, preventive care gaps]

Plan

(Organize by problem; address diagnostics, treatment, and monitoring as relevant.)

Diagnostic Clarification

(Include if abnormal liver chemistries or unclear diagnosis.)

• Confirm pattern and chronicity: [repeat labs with timing]
• Etiology evaluation: [serologies, autoimmune, metabolic tests to obtain with rationale]
• Imaging: [modality and timing]
• Goals: [identify etiology, stage fibrosis, assess for complications, initiate directed therapy]

Fibrosis Staging Strategy

(Include if fibrosis status unknown or staging will change management.)

• Step 1 — Blood-based: FIB-4 category: [low / indeterminate / high]
• Step 2 — Imaging-based: [Order / Review] elastography [VCTE / MRE / SWE] (Include if blood-based risk elevated or indeterminate. Note confounders and optimal timing.)
• Step 3 — Biopsy consideration: [Consider / Defer] liver biopsy — Rationale: [discordant noninvasive tests / uncertain etiology / results would change management / deferred because...]

Portal Hypertension and Varices Screening

(Include if advanced fibrosis or cirrhosis suspected or confirmed.)

• Portal hypertension status: [no evidence / possible / confirmed] — Basis: [platelets, spleen size, elastography, imaging signs]
• Varices screening: [EGD indicated now / Defer EGD with noninvasive follow-up] — Timing: [specify]
• Noninvasive monitoring: [repeat elastography, platelet trends, imaging] — Interval: [specify]

HCC Surveillance

(Include if cirrhosis present or HBV-related HCC risk.)

• Eligibility: [meets / does not meet] criteria — Treatment candidacy: [yes / no] — Rationale: [specify]
• Modality and interval: [ultrasound ± AFP every 6 months / alternative modality]
• Imaging quality: [adequate / limited] — Plan if limited: [switch modality / shorten interval]

Etiology-Specific Treatment

• Disease-directed therapy: [antiviral / immunosuppression / chelation / phlebotomy / metabolic therapy with regimen, dose, duration, monitoring]
• Lifestyle: [weight management plan, nutrition referral, physical activity prescription]
• Alcohol counseling: [abstinence counseling provided; pharmacotherapy or referral if AUD present]

Medication Safety and Preventive Care

• Medication safety: [hepatotoxin avoidance, acetaminophen max dose guidance, NSAID guidance if cirrhosis, dose adjustments]
• Immunizations: HAV [immune / non-immune / unknown; plan], HBV [immune / non-immune / unknown; plan]
• Nutrition: [protein and calorie goals, bedtime snack counseling] (Include if cirrhosis or sarcopenia concern.)

Orders Placed

(Optional section; include only if orders were placed.)

• Laboratories: [tests ordered with rationale]
• Imaging/elastography: [studies ordered with rationale]
• Referrals: [nutrition, addiction medicine, transplant hepatology, others with rationale]

Follow-up

• Follow-up interval: [timeframe based on acuity and pending workup]
• Communication to referring clinician/PCP: [method and timeframe]
• Pending records: [external records or images requested]

Billing

Basis: [MDM-based / Time-based]

• MDM drivers: [Number and complexity of problems; data reviewed and ordered; external records reviewed and independently interpreted; management risk]
• Time-based: Total time on date of service: [minutes] — Activities: [pre-visit review, history and exam, independent interpretation, care coordination, counseling, documentation]
• External records: [sources and date ranges reviewed] — Independent interpretation: [yes / no; specify studies]