Facebook tracking pixel
Back to Templates
Medical Doctor
10-15 minutes

Increased liver enzyme levels

The elevated liver enzymes template from s10.ai is crafted for healthcare professionals to efficiently document and evaluate liver enzyme irregularities. It features dedicated sections for capturing patient history, medication intake, alcohol use, symptomatology, and precise blood test outcomes. This template aids clinicians in formulating a detailed assessment and care strategy, incorporating lifestyle changes and necessary follow-up tests. Perfect for physicians overseeing patients with possible liver conditions, it ensures meticulous documentation and optimal patient management. Leverage this template with s10.ai to streamline your documentation workflow and boost clinical productivity.

2,321 uses
4.3/5.0
A
Alexander Carter
Template Structure

Organized sections for comprehensive clinical documentation

History:
- [Note when the patient initially became aware of their elevated liver enzymes, whether this was identified due to symptoms leading to a blood test or during routine screening. Include any previous history of liver issues or family history of liver conditions.] (Include all relevant details)
- Medications: [List all prescribed and over-the-counter medications, especially noting any that were initiated within the 3 months prior to the liver enzyme elevation.] (Include specific details about Tylenol use or history)
- Alcohol History: [Provide details of the patient's alcohol consumption, particularly in the period since the liver enzyme elevation was identified.] (Include only if mentioned)
- Symptoms: [Document any current symptoms, such as fatigue, abdominal pain, nausea, vomiting, or changes in bowel habits.] (Include details only if applicable)
Objective:
- [Include relevant blood test results, if available.] (Only include if provided)
Assessment:
- [Summarize how long the liver enzymes have been elevated and whether the patient is experiencing symptoms.] (Provide detailed assessment based on the clinical context)
Plan:
- [Detail any planned blood tests or imaging studies.] (Include all relevant investigations)
- [Outline any recommended diet or lifestyle modifications.] (Include behavior-based changes)
- [Add any additional relevant aspects of the care plan that do not fall under the previous categories.] (Include all relevant plan details)
Sample Clinical Note

Example of completed documentation using this template

History:
- The patient became aware of their raised liver enzymes during a routine check-up on March 15, 2023. There is no previous history of liver issues, although the patient's father had liver cirrhosis.
- Medications: The patient is currently on Lisinopril and began taking Tylenol for headaches about two months ago.
- Alcohol History: The patient reports drinking about 2-3 glasses of wine weekly, with no notable increase in intake since the liver enzyme elevation was identified.
- Symptoms: The patient mentions mild fatigue and occasional abdominal discomfort.
Objective:
- Blood test results from March 15, 2023, indicate elevated ALT and AST levels.
Assessment:
- The liver enzymes have been elevated for around one month. The patient is experiencing mild symptoms, such as fatigue and abdominal discomfort.
Plan:
- Plan to repeat liver function tests in four weeks to track enzyme levels.
- Advise reducing Tylenol use and limiting alcohol intake to one glass of wine per week.
- Encourage a diet high in fruits, vegetables, and lean proteins, and recommend regular physical activity.
- Arrange a follow-up appointment in six weeks to reassess symptoms and liver enzyme levels.
Clinical Benefits

Key advantages of using this template in clinical practice

  • Enhance your clinical documentation with our comprehensive template designed for evaluating elevated liver enzymes. This template meticulously guides healthcare professionals through capturing critical patient history, including the initial discovery of elevated liver enzymes, any previous liver issues, and relevant family history. It emphasizes the importance of documenting all medications, with a focus on recent changes and Tylenol usage, as well as alcohol consumption patterns. Clinicians can efficiently record symptoms such as fatigue or abdominal pain, and integrate objective data like blood test results. The assessment section aids in summarizing the duration and impact of enzyme elevation, while the plan section supports outlining necessary diagnostic tests, lifestyle modifications, and additional care strategies. Adopt this template to streamline your workflow, ensure thorough patient evaluations, and enhance clinical outcomes.
Frequently Asked Questions

Common questions about this template and its usage

Ready to transform your practice?

Join thousands of clinicians already using S10.AI to reduce administrative burden and improve patient care.

Cookie Preferences

We use cookies to enhance your browsing experience, analyze site traffic and personalize content.

Increased liver enzyme levels