MASLD/MASH Clinic Note

Date: [date of service]

Visit Type: [new / return]; [in-person / telehealth]

Provider: [name and role]

Reason for Visit: [patient-centered reason for visit] (For follow-ups, state the primary aim such as fibrosis risk review, weight-loss monitoring, or elastography results.)

HPI

(Write a focused narrative. For established patients, do not restate unchanged histories; document "reviewed, no interval change" as applicable. Omit unrelated conditions unless they affect MASLD management or medication selection.)

Liver-related history: [current symptoms and duration; prior diagnosis labels; prior workup including biopsy, elastography, imaging, and aminotransferase history; hepatotoxic medication/supplement exposures]

Cardiometabolic driver inventory: [weight history and trend]; [diabetes/prediabetes status with most recent A1c and control]; [dyslipidemia status and statin use/tolerance]; [hypertension status and control]; [OSA diagnosis and treatment adherence]; [smoking status] (Always include. Clearly indicate control status for each active condition.)

Alcohol history: [average standard drinks/week or grams/week]; [pattern and duration]; [last drink date]; [method of estimation and any uncertainty] (Always include. Quantify intake; avoid vague terms like "social drinker.")

Diet and activity baseline: [typical eating pattern including sugar-sweetened beverages and ultra-processed foods]; [protein adequacy]; [weekly minutes of moderate activity]; [resistance training frequency]; [barriers to lifestyle change]

Patient goals: [patient-stated goals in their own words] (Include if elicited.)

Objective

Vitals/Anthropometrics: [weight, height, BMI, BP, HR, waist circumference as available] (Include weight trend with dates if available.)

Exam: [general appearance]; [abdominal exam]; [stigmata of chronic liver disease if present] (Note exam limitations if telehealth.)

Labs: [hepatic panel, platelets, A1c, lipid panel, creatinine/eGFR with dates; INR if advanced disease suspected] (State "not available" for missing values relevant to staging. Omit section if no recent labs.)

FIB-4: [value]; [calculation date]; [components: age, AST, ALT, platelets]; [interpretation: low / indeterminate / high risk]; [next-step action if indicated] (If cannot be calculated, list missing components and plan to obtain.)

Elastography: [modality]; [date]; [liver stiffness in kPa]; [steatosis metric if available]; [quality indicators]; [clinical interpretation] (Include only if performed.)

Imaging: [key findings: steatosis, nodularity, splenomegaly, ascites, focal lesions]; [study quality and planned alternative if suboptimal] (Include only if performed.)

Pathology: [biopsy date]; [fibrosis stage]; [steatohepatitis activity] (Include only if performed.)

Assessment

[Brief summary of patient's MASLD/MASH status, key risk drivers, and current staging context]

• Diagnosis category: [MASLD without advanced fibrosis / MASLD with indeterminate or high fibrosis risk pending secondary testing / MASH with clinically significant fibrosis (F2 or greater) / cirrhosis due to MASLD/MASH (compensated / decompensated) / MetALD]
• Staging statement: [fibrosis risk category anchored to dated FIB-4 and elastography values; note any discordance and next diagnostic step]
• Etiology assessment: [alcohol contribution assessment]; [viral hepatitis status]; [other etiologies tested or pending] (Do not infer exclusion without documented testing.)

Plan

(Organize by problem in descending order of clinical severity. For each problem, state current status, intervention, monitoring plan, and patient counseling. Omit problem sections that do not apply.)

MASLD/MASH — Fibrosis Stratification and Liver-Directed Management

• Status: [diagnosis category and current fibrosis risk]
• Current NIT results: [FIB-4 and elastography with dates and interpretations]
• Next staging step: [repeat FIB-4 interval / elastography order / biopsy consideration / specialty referral]
• If cirrhosis suspected or confirmed: [HCC surveillance plan]; [varices screening or Baveno criteria]; [MELD if relevant]; [decompensation management if applicable]
• Patient counseling: [key points discussed about disease stage, prognosis, and monitoring]

Lifestyle Intervention and Weight Loss

• Weight goal: [target % body weight loss and timeframe]
• Diet plan: [caloric deficit approach]; [dietary pattern]; [specific targets]
• Physical activity plan: [weekly minutes of moderate activity]; [resistance training frequency]
• Behavioral supports: [dietitian referral / structured program / self-monitoring tools]; [barriers addressed and patient response]

Metabolic Comorbidities

• Diabetes/Prediabetes: [current control and A1c]; [A1c target]; [medication optimization favoring weight/liver benefit]
• Dyslipidemia: [current control]; [statin status]; [ASCVD risk and plan]
• Hypertension: [current control]; [medication plan]
• OSA: [treatment adherence and optimization plan]

MASH-Directed Pharmacotherapy

(Include only if prescribing, monitoring, or actively considering therapy.)

• Agent: [name]
• Eligibility: [diagnosis stage meeting label criteria]
• Contraindications reviewed: [list reviewed / none]
• Baseline safety labs: [acceptable / pending]
• Monitoring schedule: [liver tests interval with stop/hold parameters]; [drug interactions addressed]; [symptom precautions]
• Success metrics: [biochemical response / noninvasive markers / weight targets]
• If not prescribing: [reason and alternative plan]

Alcohol and Hepatotoxic Exposures

• Alcohol category: [below MASLD threshold / at or above threshold requiring MetALD designation]
• Counseling delivered: [abstinence or reduction guidance; resources offered]
• Other hepatotoxins: [medications/supplements reviewed and plan]

Orders and Referrals

[orders and referrals with clinical rationale for each]

Follow-up

Next visit: [timeframe]

Pre-visit tasks: [what patient should complete beforehand]