Hepatology Inpatient Progress Note

Date/Time of Service: [Date and time of evaluation]

Hospital Day / Service Day: [Hospital day number] / [Service day number]

Service: [hepatology attending / hepatology fellow / APP] — [primary / consult]

Level of Care: [floor / ICU / telemetry]

Primary Reason for Hepatology Involvement: [Reason for admission or consult]

Clinical Summary

One-liner: [Liver diagnosis and etiology] with [decompensation phenotype(s): ascites / hepatic encephalopathy / variceal bleeding / jaundice / none], [improving / worsening / unchanged]; [key contextual anchors: ICU status, infection, AKI, transplant status]. (1–2 sentences emphasizing trajectory and decision-driving factors.)

Interval Events (last 24 hours):

• [Overnight events that changed management: hypotension, bleeding, fever, mental status changes, respiratory events] (If none, state "No acute interval events.")
• [Procedures performed with key results and date/time]
• [Therapy changes with doses/targets if decision-relevant]
• [Observed response to therapy]
• (If events not yet available, state what is pending and expected update time.)

Subjective

[Patient-reported change vs yesterday: better / worse / unchanged]. [Targeted symptoms: mental status and sleep-wake pattern; GI bleeding symptoms; infection symptoms; abdominal distension and dyspnea; urine output changes; lactulose tolerance and stool frequency; oral intake]. [Direct quote of any refusals of key interventions]. (If intubated, unarousable, or no collateral available, state that subjective could not be obtained and why, then omit remaining content.)

Objective

Vitals: T [value], HR [value], BP [value] (MAP [value] if hypotension or HRS concern), RR [value], SpO2 [value]% on [room air / supplemental O2 / HFNC / ventilator], Weight [current] (Δ from admission [value], Δ from yesterday [value]).

I/O (24h): Intake [mL], Output [mL], Net [mL]; UOP [mL/kg/hr] (Include rate if AKI present.)

Exam: [General appearance]; Mental status: [orientation, asterixis present/absent]; Eyes: [scleral icterus present/absent]; Volume: [edema, JVP if assessed]; Lungs: [respiratory effort, breath sounds]; Abdomen: [distension, tenderness, ascites]; Skin: [jaundice, bruising, other findings]. (Note any deferred elements with reason.)

Pertinent Data:

• Lab trends (48–72h): Cr [trend], Na [trend], TBili [trend], INR [trend], Hgb [trend], WBC [trend], Plt [trend]. (Include timestamps; emphasize direction of change for decision-driving labs only.)
• Microbiology: [Specimen, collection date, preliminary/final status, organism(s), sensitivities if available]. (Summarize actionable findings only.)
• Imaging/Procedures: [Key results with dates: paracentesis PMN count and culture status, ultrasound/Doppler findings, EGD findings]. (Extract actionable findings; do not copy full reports.)

MELD/Transplant Context: [MELD-Na / MELD 3.0] = [score] (Cr [value], Bili [value], INR [value], Na [value], Albumin [value if MELD 3.0]; labs from [timestamp]) — Dialysis: [yes / no]. Transplant: [listed / evaluation in progress / not a candidate: reason]. (Include for advanced disease, transplant consideration, or rapidly changing status.)

Assessment & Plan

(Organize by problem from most to least urgent. For each problem: status/trend, supporting data, brief assessment, today's plan, monitoring approach, and explicit contingency with if/then triggers.)

[Problem 1]: [Diagnosis or issue]

• Status: [improving / worsening / unchanged] — [supporting trend data].
• Assessment: [Brief reasoning: suspected precipitant, severity, risks].
• Plan: [Therapies with doses/targets], [tests], [procedures], [consults], [diet/sodium strategy].
• Monitoring: [Parameters and frequency], [therapeutic targets].
• Contingency: If [trigger], then [escalation action].

[Problem 2]: [Diagnosis or issue]

• Status: [improving / worsening / unchanged] — [supporting trend data].
• Assessment: [Brief reasoning].
• Plan: [Actions].
• Monitoring: [Parameters and frequency].
• Contingency: If [trigger], then [action].

(Continue for additional active problems as needed.)

Common Hepatology Problems (include only if active)

Hepatic Encephalopathy

• Status: [Grade], asterixis [present / absent], [stool count/24h], [precipitant identified or under evaluation].
• Plan: Lactulose [dose/route] targeting 3–4 BMs/day; [Rifaximin if indicated]; [address precipitant]; [aspiration precautions if indicated].
• Contingency: If no BMs or worsening mental status, then [enema / escalate therapy / airway protection / higher level of care].

Ascites/Volume Management

• Status: [Distension], [edema], [weight Δ], [diuretic tolerance], [Na trend].
• Plan: [Diuretic regimen with spironolactone:furosemide ratio]; [paracentesis plan]; [albumin replacement]; [Na/fluid restriction].
• Contingency: If AKI, hyperkalemia, or hyponatremia, then [hold/adjust diuretics, albumin, reassess; TIPS consult if refractory].

AKI / Suspected HRS-AKI

• Status: Baseline Cr [value], current [value and trajectory], [hemodynamics], [nephrotoxin exposure].
• Plan: [Albumin challenge dosing]; [vasoconstrictor and MAP target if HRS]; hold [nephrotoxins/diuretics]; [infection evaluation].
• Contingency: If no response to albumin or worsening, then [start/adjust vasoconstrictor, ICU/nephrology consult].

Infection / SBP Concern

• Status: [Fever/WBC], paracentesis PMN [value] and culture [status], [source evaluation].
• Plan: [Empiric antibiotics with de-escalation criteria]; albumin [day 1 and day 3 dosing]; [source control].
• Contingency: If clinical deterioration or PMN rise, then [broaden antibiotics, repeat paracentesis, escalate care].

Portal Hypertension / GI Bleeding

• Status: [Active bleeding: yes/no], [Hgb/platelet trends], [known variceal status].
• Plan: [Resuscitation targets]; [vasoactive therapy]; [antibiotic prophylaxis]; [PPI]; [EGD timing].
• Contingency: If ongoing bleeding or hemodynamic instability, then [massive transfusion protocol, airway protection, urgent EGD/TIPS consult].

Transplant / Goals of Care / Disposition

• Status: [Listed / evaluation in progress / not a candidate: reason].
• Plan: [Inpatient evaluation steps], [consults], [documentation needs].
• Communication: Code status [full / DNR / DNI / comfort], [family updates].
• Disposition: [Anticipated discharge plan and barriers], [follow-up].

Prophylaxis: VTE [given / held: reason]; GI [indicated / not indicated / held]. (Include only if clinically significant decision.)

Pending Data: [Awaited results and clinical relevance]; expected by [time]. Reassess at [time] with [specific decision to make].