Hepatology SOAP Note

Date: [Date]

Patient: [Patient]

Visit Type: [New / Established]

Provider: [Provider]

Liver Disease Snapshot

(Safety-critical block. Use "Unknown - pending records/workup" for missing items rather than omitting.)

Etiology: [Known or suspected etiology]

Stage: [Fibrosis stage or cirrhosis status; if cirrhosis: compensated / decompensated]

Severity Scores: [If cirrhosis: MELD-Na and Child-Pugh with date; if no cirrhosis: "N/A - no cirrhosis"]

HCC Surveillance: [If at-risk: last test with date/result and next due; if not indicated: brief reason why]

Portal HTN/Varices: [Screening status with date/result; prophylaxis if applicable]

Transplant Status: [Not indicated / Referred / Listed] (Include only if clinically relevant.)

Subjective

Chief Complaint: [One-line reason for visit] (Use patient's words when symptom-based.)

Interval History: [Narrative summary covering disease context, interval symptoms, decompensation events if cirrhosis, medication adherence/response, and alcohol use when relevant] (For new patients: onset, prior workup, risk factors. Include pertinent negatives only when they meaningfully narrow clinical risk.)

Medications: [Liver-relevant medications with doses] (For cirrhosis: note adherence and response indicators such as lactulose BMs/day or weight trend on diuretics.)

Objective

Vitals: [BP, HR, weight with trend if relevant]

Exam: [Pertinent findings: icterus, abdominal distension/fluid wave, asterixis, edema, general appearance] (Note limitations if telehealth.)

Data: [Key labs with dates and trends; calculated scores (FIB-4, MELD-Na/Child-Pugh as applicable); relevant imaging findings; recent procedure results] (Emphasize clinically meaningful changes.)

Assessment & Plan

[1–2 sentence synthesis: current liver diagnosis, stage, stability, and key decisions today]

[Problem 1]: [Condition with etiology/stage]

Assessment: [Brief status with key supporting data]

Plan: [Diagnostics, medication changes with rationale, monitoring parameters, patient counseling, and follow-up interval] (Address as single narrative or brief list based on complexity.)

[Problem 2]: [Condition]

(Continue additional problems in order of clinical priority. Keep assessments concise.)

Assessment: [Brief status]

Plan: [As above]

(For cirrhosis patients, ensure documentation addresses: ascites management, variceal prophylaxis, hepatic encephalopathy, HCC surveillance, and transplant considerations—either within a unified cirrhosis problem or as separate problems.)

Orders & Follow-up

Orders: [Labs, imaging, procedures, referrals with timeframes]

Follow-up: [Next visit interval and criteria for sooner return] (Include return precautions: bleeding, confusion, rapid weight gain, fever.)