hospitalist Template

Free AI CHF Assessment & Plan Template

AI-enhanced template for acute on chronic heart failure exacerbation. Includes annotations, clinical decision points, and a filled example from a practicing hospitalist.

By Nahom Nigussie, Founder & CEO, Aclera AI

Heart failure exacerbation is one of the most common hospitalist admissions, and the assessment and plan section requires structured clinical reasoning across volume management, etiology workup, medication optimization, and disposition planning. This condition-specific template goes beyond generic A&P formats to address the clinical decision points that hospitalists face with CHF patients, from diuretic strategy and BNP trending to guideline-directed medical therapy optimization before discharge. Includes a filled example with annotations explaining the reasoning behind each management decision. Reviewed by a practicing hospitalist and designed for use with AI documentation tools like CasePanel.

TL;DR

When to use this template:

  • Admissions for acute on chronic heart failure exacerbation
  • Daily progress notes for CHF patients requiring diuresis
  • Discharge summaries documenting heart failure management

What it includes:

  • HF classification with EF documentation
  • Structured volume status assessment with exam findings
  • GDMT status table aligned with ACC/AHA 2022 guidelines
  • Weight tracking with goal-directed therapy
  • Disposition planning with follow-up coordination

The Template

Copy the block below and customize for your patient:

# Acute on chronic [systolic/diastolic] heart failure exacerbation ([HFrEF/HFpEF], EF [XX]%)

**Etiology:** [Ischemic/Non-ischemic cardiomyopathy, details]
**Precipitant:** [dietary indiscretion / medication non-adherence / infection / arrhythmia / ischemia / unclear]

**Current volume status:** [Hypervolemic/Euvolemic/Hypovolemic]
- JVP: [XX cm at 45°]
- Peripheral edema: [X+ bilateral LE edema to level]
- Lungs: [crackles location / clear]
- Weight: [XX.X kg] (Admission: [XX.X kg], Goal: [XX kg])
- I/O: [Net +/- X L over past 24h]

**Diuretics:**
- [Current regimen with dose]
- Target: [net negative X L/day until goal weight]
- Plan: [Transition to PO when ...]

**GDMT Status (per ACC/AHA 2022 Guidelines):**
| Class | Medication | Status | Notes |
|-------|------------|--------|-------|
| ARNI/ACEi/ARB | [Drug dose] | [On/Starting/Holding] | [Reason] |
| Beta-blocker | [Drug dose] | [On/Starting/Holding] | [Reason] |
| MRA | [Drug dose] | [On/Starting/Holding] | [K+ level] |
| SGLT2i | [Drug dose] | [On/Starting/Holding] | [eGFR, notes*] |

**Disposition:**
- Target discharge: [when goal weight achieved, euvolemic on PO]
- Follow-up: [Cardiology in X weeks, PCP in X days]
- Education: [Heart failure education by nursing, dietary counseling]

*SGLT2i renal considerations for HF:
- Dapagliflozin: FDA labeling does not recommend initiation at eGFR <25 mL/min/1.73m². If eGFR falls below 25 during treatment, the label allows continuation at 10 mg daily for cardiorenal benefit.
- Empagliflozin: HF trials included patients with eGFR ≥20 mL/min/1.73m². Efficacy and safety trials did not enroll patients with eGFR <20 or on dialysis; enrolled patients were not required to stop if eGFR later fell below 20 or dialysis began.
Check the specific agent's current labeling and the patient's clinical status when deciding whether to initiate or continue treatment.

Renal prescribing sources: FARXIGA prescribing information, §2.3 and JARDIANCE prescribing information, §8.6.

Why This Works

1. EF and HF Classification Matter for Treatment

Specifying HFrEF vs HFpEF and the ejection fraction is not academic documentation. It directly determines which therapies have mortality benefit:

  • HFrEF (EF ≤40%): All four GDMT pillars (ARNI/ACEi/ARB, beta-blocker, MRA, SGLT2i) have Class I indications per ACC/AHA 2022 guidelines
  • HFpEF (EF ≥50%): SGLT2i has a Class I recommendation in the ESC 2023 focused update, based on EMPEROR-Preserved and DELIVER, to reduce HF hospitalization or cardiovascular death; diuretics for congestion; other agents have less robust mortality evidence
  • HFmrEF (EF 41-49%): ACC/AHA 2022 supports GDMT optimization similar to HFrEF

Anyone reading your note (consultants, night float, outpatient providers) immediately knows the treatment framework.

2. Volume Status Documentation Drives Daily Decisions

The structured volume assessment (JVP, edema, lungs, weight, I/O) creates a trackable trajectory. This matters because:

  • Diuretic dosing depends on response trends, not single data points
  • Discharge readiness requires documented euvolemia
  • Readmission risk correlates with inadequate decongestion

Consistently documenting these five elements creates a clear narrative of decongestive progress.

3. The GDMT Table Prevents Omissions

A table format forces explicit documentation of all four medication classes. This prevents the common failure of optimizing familiar drugs while neglecting newer evidence-based therapies (especially SGLT2i).

The “Status” and “Notes” columns capture why a medication is held. This is critical information for the next provider titrating therapy.

Filled Example

[SYNTHETIC EXAMPLE - Not a real patient]

Here’s a synthetic example showing how this template looks in practice:

# Acute on chronic systolic heart failure exacerbation (HFrEF, EF 30%)

**Etiology:** Ischemic cardiomyopathy s/p LAD stent 2022
**Precipitant:** Dietary indiscretion + medication non-adherence (ran out of furosemide)

**Current volume status:** Hypervolemic, improving
- JVP: 10 cm at 45° (down from 14 cm on admission)
- Peripheral edema: 2+ bilateral LE to mid-shin (improved from 3+)
- Lungs: Clear (previously bibasilar crackles)
- Weight: 94.2 kg (Admission: 99.0 kg, Goal: 90 kg)
- I/O: Net -1.5 L over past 24h

**Diuretics:**
- Furosemide 80 mg IV BID (was 40 mg PO daily at home)
- Target: net negative 1-2 L/day until goal weight
- Plan: Transition to PO furosemide 60 mg BID when euvolemic x24h

**GDMT Status (per ACC/AHA 2022 Guidelines):**
| Class | Medication | Status | Notes |
|-------|------------|--------|-------|
| ARNI/ACEi/ARB | Sacubitril-valsartan 24-26 mg BID | On, at low dose | Uptitrate after discharge |
| Beta-blocker | Carvedilol 6.25 mg BID | On | Held day 1-2, restarted |
| MRA | Spironolactone 25 mg daily | On | K+ 4.2, Cr 1.1 |
| SGLT2i | Dapagliflozin 10 mg daily | Starting today | eGFR 68, new addition |

**Disposition:**
- Target discharge: Tomorrow if euvolemic on PO diuretics x24h
- Follow-up: Cardiology in 2 weeks, PCP in 5 days, HF clinic call in 48h
- Education: Heart failure education completed, 2g sodium diet reviewed, daily weights emphasized

Checklist

Before finalizing your note, confirm:

  • EF and HF type (HFrEF/HFpEF/HFmrEF) documented
  • Precipitant identified or explicitly noted as unclear
  • Volume status with specific exam findings (JVP, edema, lungs)
  • Weight trend with admission weight and goal weight
  • GDMT status for all 4 pillars with rationale for any holds
  • Diuretic plan with target and transition criteria
  • Disposition plan with follow-up appointments

Learn the clinical reasoning behind this template structure:

CHF Assessment & Plan: A Framework for Documentation - A detailed look at the evidence supporting each section of this template, including landmark trials and guideline recommendations.

Last reviewed: 2026-01-20. Clinical content based on society guidelines, FDA labeling, and pivotal trials available at review date. Verify against current sources before clinical use.